1. Children’s Emergency Services
CES Current State and Opportunities for Improvement
Final Report
April 18, 2017
IOE 481 Team 2
Gagan Gupta, Anavir Shermon, Emily Smith, Hailey Willett

2. Focus on quality care of patient while maintaining patient safety
Process
Arrival
Assessment
Treatment
Disposition
Planned/Unplanned Arrival
Safe/Unsafe
ID Band/Severity Level
Triage Nurse
Primary Nurse
Resident/Attending Physician
Order diagnostic tests
Treatment by physician/nurses
Treatment by consultant
Discharged
Admitted for observation or inpatient care
Other (transfer to OR, expire, etc.)
Overall Goal of CES
Focus on quality care of patient while maintaining patient safety

3. Key Issues
Diversion from procedures due to required impromptu decision making & frequent distractions
Nurses and physicians are often overwhelmed due to variability in arrival patterns
Requirement to bypass standard process when high acuity patient arrives causes chaos.
Unable to gauge acuity of patients due to inability to communicate
Nurses spend longer than necessary getting patient background

4. Goals & Objectives
Reduce NVA time from process steps
Reduce cognitive load on staff 2 3
Improve CES Operations by focusing on Patient Safety and Quality of Care
Develop detailed Value Stream Map
Increase patient throughput 1 4
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Identify opportunities
for improvement 6 5
Eliminate bottlenecks in process flow

5. Methods Gemba Walks Time Studies Nurse and Provider Survey
Data Analysis
Literature Review
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6. Gemba Walks Documentation Interruptions Inefficiencies
Some triage nurses document in the room during triage, while some document after outside in the central staffing area
Charting can still be happening 2-3 hours after the patient leaves
Attending physicians often get interrupted by phone calls or questions
Consult calls can hold up process
Attending's must handle and approve all transfers
Portable weight scales located far away
Residents/PAs can administer full treatment depending on condition, but still need to be checked/signed off by attending
Attending physician handoffs take significantly longer than primary care nurse handoffs between shifts
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7. Front Desk Observation Spreadsheet

8. Data Collection Log

9. Qualtrics Survey Add lesson learned for this
Easier to crowdosurce (have everyone there at the same time…dont make it too complicated...remind people its not about them...everyone has different perceptions and interpretations of what the process steps really encompass

10. Findings & Conclusions Figure 1: Front Desk Process & Wait Times
Limitations of data collection
Sample Size: 106, Source: IOE 481 Team, Collection Period: February-March 2017

11. Findings & Conclusions
Figure 2: Percentage of Triage & Primary RN Eval that occur Individually or Simultaneously
Total Process Time when
evaluated individually: 22 min
Total Process Time when
evaluated simultaneously: 15 min
Key Insight
Total Process Time is 37.8% shorter when Triage and Primary RN Eval occur simultaneously

12. Findings & Conclusions Figure 3: Nurse and Provider Process Times
Sample Size: 75, Source: IOE 481 Team, Collection Period: February-March 2017

13. Excel Data Summary Sheet

14. Excel Data Summary Sheet

15. Excel Data Summary Sheet

16. Final Value Stream Map
88 min

17. Final Value Stream Map (Part 1)

18. Final Value Stream Map (Part 2)
88 min

19. Application of Lean in the ED Redesigning ED patient flows (Flinders)
Literature Review
Application of Lean in the ED
(Dickson et al., 2009)
Redesigning ED patient flows (Flinders)
(King et al., 2006 in Australia) 1 2
Action
Improved signage for directing patients.
Laboratory tests/X-ray studies ordering and sending done earlier in the process
Nurse, resident, and attending get the patient’s history simultaneously, reducing duplication of history and saving staff time
Result
Triage WT decreased from 3.18 to 2.63 mins
Evaluation WT decreased from mins to mins
Action
Creation of patient “streams” for patients predicted at triage to be admitted or discharged (or fast tracked)
Functional team of nurses and doctors dedicated to each stream
Result
Mean LOS for dischargeable patients reduced from 3.7 to 3.4 hours, and admitted from 8.5 to 7.0 hours (statistically significant)
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20. Figure 5: Impact-Effort Matrix Thankless Initiatives
Recommendations
Figure 5: Impact-Effort Matrix
Quick Wins
Stars
Stream System
Standardization of Process Steps
Simultaneous Evaluation
On-the-go digital documentation
Impact
Low Hanging Fruit
Thankless Initiatives
Addition of Signage
Automation of Registration Process
Potential re-purposing of café entrance desk
Effort

21. Standardization of Process Steps
Front Desk
Triage
Lab & Imaging
Admittance
Picture credits: (1) Icon made by Freepik from 

22. Low Acuity Stream (Fast Track)
Stream System
Assigned nurses, attendings, and residents focus on quick turnover of dischargeable patients
Shared resources, staff, and rooms as needed
High Acuity Stream
Frees resources, staff, and space for high acuity patients, and will reduce overall LOS for all patients
Screener Nurse predicts whether patient will be admitted or discharged
Icons by Roundicons and Popcorn Arts on
Low Acuity Stream (Fast Track)

23. Stars
Online app and/or multiple automated stations for transfer patients, referral patients, and low acuity patients to check-in rather than wait in queue
Concurrent diagnosis of patient by nurse, resident, and attending to minimize repeated gathering/transfer of medical history
Icons by Roundicons and Popcorn Arts on

24. Measurement of Wait Time
Future Directions
Disposition & Discharge
Diagnosis & Treatment
Measurement of Wait Time
Picture credits: (1) Icon made by Freepik, Icon Works, and Madebyoliver from 

25. THANK YOU