Hunterdon Medical Center – Case Study 2

The Hunterdon Medical Center is a 176-bed, non-profit community hospital serving the greater Flemington, NJ area.  It provides a full range of preventive, diagnostic, and therapeutic inpatient, outpatient, and community health services.  The center has an active continuous process improvement program focusing on the priorities of safety, quality, patient satisfaction, finances and the community.  DeBaylo Associates was asked to help the organization learn basic Six Sigma tools and apply them to a couple of critical clinical areas.  Two projects resulted.

Project 2 – Emergency Department Patient Flow

Challenge

In 2005, the Emergency Department was experiencing an increase in the number of patients served, partly due to the opening of new ED facilities and partly due to changing demographics and community needs.  This increase was stressing the staff and facilities which were nearing or exceeding capacity.  Average patient stay, from triage to disposition time, increased to 129 minutes, leading to increasing patient dissatisfaction. 

This growth trend was projected to generate an additional $2.5 million in net revenue for the medical center in 2006.  The challenge was to achieve this growth, while controlling expenses which could easily exceed $300,000.  Also, there was a desire to improve patient satisfaction by reducing their time spent in the ED.

It was thought that both objectives could be achieved at the same time.  By reducing the cycle time of patient flow to a goal of 130 minutes (best practice is 130 minutes for patients that were discharged), the projected increase in patients could be absorbed with little additional cost. A second goal was set to reduce the time from triage to arrival on an inpatient care unit to 4 hours (for admitted patients).

Approach

A cross functional team was established early in 2005 to address the patient flow issues. They flow charted the key sub-processes and began brainstorming areas for improvement.  What was lacking was a data driven approach to help the team focused on the vital few areas and root causes.  DeBaylo Associates was asked to help the team apply Six Sigma PEP tools to this project so the team could become more productive and effective.

Baseline data was collected.  Since 82% of the patients in the ED are treated and released, this group uses the bulk of the ED capacity and hence was the first area to be evaluated. Cycle times for each sub-process were measured. The largest amount of time was spent in the “doc to disposition” sub-process, which also had the highest variability. Within this sub-process, various test durations were analyzed and stratified by shift, day of the week, and diagnosis code.  Also patient records were reviewed for doc to disposition times greater than 5 hours. Numerous observations were made such as length of troponin testing, which varied by day of week and shift, and excessive transportation delays for getting patients to and from the x-ray facility.

It was noticed that 55% of the ED patients were admitted between 7 p.m. and 7 a.m. Also, 65% of the admitted patients come from the ED, the bulk between 4 p.m. and 1 a.m. This did not align with hospital staffing.

Three areas outside the doc to disposition sub-process also became quick hit opportunities: 1) time from arrival to triage, 2) time from diagnosis to release, and 3) the use of the Fast Track process.  Separate subcommittees were formed to address each of these processes.

Results

A permanent clinical coordinator nurse role has been created.  This person has oversight of patient flow in the ED. 

New Laboratory equipment was purchased to speed up the results of troponin testing. Although only about 2% of patients have two or more troponin tests completed, a much larger percentage of patients have one troponin test completed while in the Emergency Department.  The number of tests is expected to increase due to the reduced test time – resulting in better patient care.

A new radiology room was opened up in the ED to eliminate patient transport delays and improve overall care. Total cycle time reduction will be measure in 2007 once the new facility processes stabilize.

A new triage process was implemented, including a simplified computer input screen, training of additional ED nurses to do triage so responsibility is shared, and a second triage nurse was added from 12pm-12am to accommodate increased patient volume.  The physical layout of the registration/triage area is in the process of being altered to allow for faster triage.  Flexible shifts were added for triage nurses during busy times. The anticipated cycle time reduction is 15 minutes.

The ED discharge process was revamped.  Three new techs were trained to speed up the process and a new ‘float” nurse was added to the staff to also help expedite discharges. It was decided to expand the hospitalists’ hours to better fit the volume of admits from within ED.  Also, a new vendor was chosen for computer generated discharge instructions, which will cut down on confusion, questions, and delays.

Further work

Work will continue to be completed in the area of triage as the physical layout changes will be completed as well as a five level triage severity process that will be implemented in August 2007 to better classify and prioritize care of patients.

A team has been formed to assess the Fast Track program.  It was initially set up to identify less critical patients and send them through a separate process within the ED.  The idea was to speed the least critical patient through the ED freeing up ED resources for the sicker patients.  Only 23% of the level 2 patients utilized the fast track process.  When measured, there were no differences between the mean, median and shifts between fast track and non-fast track patient cycle times. Improvements in Fast Track will free up beds in the main part of the ED i.e., increased capacity.  To date, all staff positions have been filled allowing for Fast Track to remain open during its regularly scheduled operating hours.  The Director of the Emergency Department also shifted staffing to better staff Fast Track as well as the main ED.  Pharmacy reorganized the physical location and types of medications available for Fast Track patients to better serve that population.  Storage areas were created in each Fast Track room to better provide supplies to staff for common Fast Track diagnoses and issues.  A mobile orthopedic cart was created to better serve all ED patient rooms.  Finally, the hospital will consider the expansion of Fast Track operating hours if patient volume warrants this change.

The larger team decided to refocus their efforts on the back end of the process when patients are admitted.  Since action plans are being put into place for the treat and release processes, and additional outcome measures are being installed in 2007, this will provide new direction and motivation for the team.