1. Children’s Emergency Services
Children’s Emergency Services (CES) Current State and Final Recommendations for Improvement
IOE 481 Team 5
Matthew Hoberman
Denise Jue
Josefina Moni
Dr. Prashant Mahajan
Ms. Elizabeth Duffy
Dr. Mark Van Oyen
Final Presentation
17F5-final-report
12 December 2017

2. Background
Children’s Emergency Services (CES) provides healthcare for children and young adults
Vice Chair of Emergency Medicine asked an IOE team to investigate the following:
Issues with evaluation, diagnosis, treatment, and disposition
Variations in LOS due to resident workload/experience level and patient acuity
Delays and bottlenecks in the patient length of stay (LOS)

3. Goals & Objectives
Record and analyze non-clinical and clinical time to improve resident/PA workflow
Characterize the working behavior and tasks of residents/PA
Evaluate non-clinical tasks to find bottlenecks
Minimize the time from the point of initial doctor evaluation to disposition
Discriminate and characterize the working behavior of resident - components of resident’s workflow and tasks
Objective: eliminate non value added time

4. Identify Bottlenecks to reduce Length of Stay within CES
Team Approach
Time Studies
Gemba Walk
Identify Bottlenecks to reduce Length of Stay within CES
Historical Data Analysis
Observed Data Analysis
Literature Review

5. Time Studies Collection Period: October 2017 - November 2017
Shadow Residents (Level 1 - 4) and Physician’s Assistants (PA)
18 providers
Record patient room number, patient acuity, resident/PA workload and experience level
~100 patient cases
Document each event with start time and end time
~1000 discrete events

6. Data Collection Sheet

7. Data Collection Describing Clinical and Non-Clinical Events
Clinical Time
In Patient Room
IE: Initial Evaluation
First contact with provider
E: Evaluations in Room
Subsequent evaluations
Non-Clinical Time
RC: Review Chart
CX: Consults (Excluding Attendings)
CA: Consult Attending
WO: Write Order
GC: General Charting
D: Filed for Disposition
N: Notes (Other)

8. Time Study Results Collection Period: October 2017 - November 2017
Observed Clinical (%):
Total Clinical Time
Total Time Observed
Observed Non-Clinical (%):
Total Non-Clinical Time
Total Time Observed

9. Time Study Results Collection Period: October 2017 - November 2017
Event
Sample Size (n)
Mean (mm:ss)
Median (mm:ss)
Avg # Events per Patient
Evaluation (E)
112
5:11 3
1.70
Initial Eval (IE) 58
9:12
9:15
1.00
Consult (CX)
172
2:00
1:15
2.62
Consult Att (CA)
147
2:02
1:34
2.12
Review Chart (RC)
141
1:45
1:28
2.20
General Charting (GC)
183
2:49 2
2.47
Write Orders (WO) 82
1:38
1:12
1.73
Filed for Disposition (D) 44
2:15
1:55
1.39
Total
939 (~58 hours) --

10. Current Value Stream Map IOE 481 Winter 2017 Team [1]

11. Enhanced Value Stream Map Resident/PA Task Workflow
One Patient Instance - Task Order Varies
No observed waiting time for the resident/PA

12. Time Study Events General Distribution
Evaluation
Initial Evaluation
Consult
Consult Attending
Review Chart
General Charting
Write Orders
Discharge
Home
---- Cumulative Percentage

13. Time Study Events Provider Distribution
Evaluation
Initial Evaluation
Consult
Consult Attending
Review Chart
General Charting
Write Orders
Discharge
Home

14. Time Studies Events Patient Acuity Distribution
Evaluation
Initial Evaluation
Consult
Consult Attending
Review Chart
General Charting
Write Orders
Discharge
Home

15. No Correlation Found With Experience
Collection Period: January October 2017
*Only Admissions

16. No Correlation Found With Experience
Collection Period: January October 2017
*Only Discharges

17. Patient Distribution Acuity and Average Time to First Provider Contact
Average* (mm:ss)
1 (0.17) 2
19:00
2 (31.69)
379
30:21
3 (42.06)
505
44:58
4 (25.25)
302
51:30
5 (0.84) 10
33:06
*Time between Arrival and First Provider Contact

18. Patient Fast Track

19. Documentation Final Observations
General Charting most time consuming non-clinical task
Establish best practice of documenting while evaluating (iPads/Laptops)
Further investigate tradeoffs of in-room documentation
General Charting (%)

20. Managing Interruptions Final Observations
Large number of interruptions observed
Phone calls during evaluations in the room
High cognitive load - many patients at a time
Visual Signage
Develop best practices or standards in prioritization
Further investigate existing policies

21. Further Data Collection
Gather more time studies data for more statistically accurate findings
Investigate disposition to discharge and admittance
Explore workflow tasks of nurses and attendings

22. Department of Industrial Operations Engineering
Contact Information
Matthew Hoberman
Department of Industrial Operations Engineering
Denise Jue
Josefina Moni

23. References
[1] G. Gupta, A. Shermon, E. Smith, and H. Willet(2017). “Using Lean Tools to Identify Opportunities for Improvement in the Michigan Medicine Children’s Emergency Services,” Ann Arbor, MI, 2017