DGH Emergency Department Wait Time Improvement Project: Part 1 Patient Fast TrackQuality Week May 29, 2014

Acknowledgements - Project Team

Name Title Project RoleLori Sanderson Health Service Manager Co-Lead

Liam Shannon Management Engineer Co-Lead

Ravi Parkash Chief, Emergency Medicine Co-Lead

Mark McMullen MD Contributor

Albert Williams MD Contributor

Don MacQuarrie MD ContributorDon MacQuarrie MD Contributor

Heather Peddle-Bolivar MD Contributor

Sherry Lynne Jessome RN / Clinical Nurse Educator Contributor

Pam McKinnon RN Contributor

Carolyn Peters RN Contributor

Nancy Strickland RN Contributor

Channa Lee Haas RN Contributor

Lee Mailman RN Contributor

Arlene White RN ContributorArlene White RN Contributor

Trisha Sanford RN Contributor

Jean Law RN Contributor

Cynthia Hodgins RN Contributor

Heather Francis Health Services Director Sponsor / Supportp pp

Barbara Hall VP Person-Centered Health Sponsor / Support

Dave Urquhart IT ED Contributor

Sherri Lamont Admin Assistant, DGH ED Contributor, Admin Support

Overview

• BackgroundTh P blo The Problem

o The Challengeo Strategic Alignment

E i d f Cho Equipped for Change

• Project Executiono Methodso Patient Satisfaction Driverso Core Focuso Baseline Measureso Proposed Solutiono Required Operational Changeso Success Factors

• Statistical Results

Background

2011 / 2012:Hospital Capacity • DGH Hospital Occupancy > 100%• ED Volume approaching 40,000 visits per year• LOS Admitted Patients in the ED 22 – 25 hours

Emergency Department • Increasing Wait TimesIncreasing Wait Times• Increased left without being seen (LWBS)• Patient complaints and poor patient satisfaction • Frustrated and stressed Staff

Background

35

40

45

25

30

S (h

ours

)

10

15

20

LOS

0

5

90th %ile

Defining the Problem

Problem focus areaso Patient wait times excessively long

o Not meeting desired customer service level

o Not satisfying patient expectations

N t ff ti l i ti t d d d flo Not effectively managing patient demand and flow

in the ED

The Challenge

Department was challenged byp g yAdministration to maximize efficiency andimprove patient satisfaction without theimprove patient satisfaction without theaddition of major resources

o Find ways to do better with the sameo Ensure the ED is a sustainable system

Strategic Alignment

Aligned with Capital Health’s renewedorganizational strategy - Our Promise in Action:

B ild lt f t io Build a culture of customer serviceTransforming the Person-centered Health Care Experience

o Strengthen accountability of employees and PhysiciansTransformational Leadership

o Innovate systems and processes for greater efficiencySustainability

Equipped for Change

• Fall 2013: Stable staffing situation, major free agent i isigning

• Keen new young staff willing to embrace change• Keen, new, young staff willing to embrace change

• Many staff came from other departments across the y pcountry bringing different ideas and experience

• Concentrating on flow issues within the control of the ED

• Clear focus and objectives

Methods

The initial project work consisted of acomprehensive assessment of the system

• This work included: o An environmental scano Process Mappingo Data collectiono Review of ED resource capacityo Team discussions

Analysiso Analysis

Drivers for Patient Satisfaction

• Major drivers for patient satisfaction in ED visits– Empathy / Attitude– Timeliness of Care (waiting time)– Technical Competence of Care Providers– Pain Management – Information Dispensation

• Minor drivers for patient satisfaction in ED visits – Cleanliness– Comfort in waiting roomComfort in waiting room– Privacy– Noise levels

“Leading Practices in Emergency Department Patient Experience”, Ontario Hospital Association (2010/2011)

Core Focus

• During the literature review, a highly compelling quote stood out and became the core focus for the teamstood out and became the core focus for the team

“Ensuring the most rapid possible contact with a physician satisfies the g p p p ydesires of ED patients, promotes efficiency of care and shortens length of stay”.

Leading practices in Emergency Department Patient Experience; Ontario Hospital Association (2010/2011)

Goal: Decreased door to doctor time for CTAS 4 and 5 patients

Satisfaction Survey

Baseline Measures

Critical to Quality Performance Metric

CTAS 4 CTAS 5

Weekly mean door to doctor 132.1 minutes 126.7 minutesytimeWeekly mean length of stay 233.6 minutes 197.5 minutes

Weekly 90th percentile 240 2 minutes 217 5 minutesWeekly 90t percentile 240.2 minutes 217.5 minutes

Weekly % <90 minutes 36.5% 39.7%

Team Findings

Low acuity patients have long wait timesy p gimpacted by...

• Traditional model of Triage-Registration-Waiting Room- ED bed

• Traditional nurse then physician model

• Traditional use of physical beds

• Staffing hours not aligned with demand

Proposed Solution

• Creating a fast track into the ED for low acuity patients by...

• Challenging the three existing paradigms

o Revising the traditional flow of patients into the

department

o Changing the way we used physical beds

o Minimizing the nurse first modelg

Required Operational Changes to Support The New ModelSupport The New Model

• Role of registration clerk was expanded to direct low acuity

patients directly into the ED

• The flow of the patient’s chart changedThe flow of the patient s chart changed

• The concept of patients being screened by the nurse was

introducedintroduced

• Changes to physical space were made

• The hours of operation of the fast track area were adjusted

• RN/MD staff hours were adjusted

Success Factors

• Started with a blank slate

• Focused on the pieces of the process within ED control

• Worked with a specific and definable objective

• Attempted to control distraction

• Continual monitoring and check ins• Continual monitoring and check ins

• Supported team work and collaboration

Statistical Results

“Ensuring the most rapid possible contact with a physician satisfies the desires of ED patients promotes efficiency of care and shortens lengthdesires of ED patients, promotes efficiency of care and shortens length of stay”.

Leading practices in Emergency Department Patient Experience; Ontario Hospital Association (2010/2011)Hospital Association (2010/2011)

Our core focus helped to define our testing hypotheses:

• Will the planned changes have an impact on rapid contact with Physicians?

• Does rapid contact with a Physician satisfy the desires of the p y ypatient?

• Does rapid contact with a Physician promote efficiency of care and shorten length of stay?g y

Critical to Quality Measures

1. Weekly % of CTAS 4 and CTAS 5 patient going directly to waiting roomroom

This metric is to ensure that the opportunity for quicker access to physician is possible by placing patients in an area where the next phase of treatment may occur

2 Weekly mean Door to Doctor for CTAS 4 and CTAS 5 patients2. Weekly mean Door to Doctor for CTAS 4 and CTAS 5 patientsBased on the core focus of satisfying the desire of rapid access to Physician assessment

3. Weekly 90th percentile door to doctor time for CTAS 4 and CTAS 5 y ppatients

Ensure that the metrics are not only responding to central data tendencies but also the variation in performance

4 Weekly % of patients with Door to Doctor time <90 minutes for CTAS 44. Weekly % of patients with Door to Doctor time <90 minutes for CTAS 4 and CTAS 5 patients

Aligning performance with a defined standard of care for low acuity ED patients

5. Weekly mean length of stay for CTAS 4 and CTAS 5 patientsy g y pBased on the presumed correlation between rapid contact with Physician and shortened length of stay

Flow Logic

May still take some time to see a Doctor,yHowever:

P ti t i Ph i i t t• Patients in Physician assessment queue supports patient flow – Patients are accessible and ready to be seen, visual queue of pending workload

• Patients in a location where the next phase of treatment may take placetreatment may take place

• In the correct queue; waiting room adds no value to ti t ipatient experience

Intake and Patient Flow

Low Acuity Direct to Waiting Room

Percentage of low acuity Patients Direct to Waiting Room

96.0%

98.0%

Room

92.0%

94.0%

90.0%

92.0%

86.0%

88.0%

Low Acuity Direct to Waiting Room

120.0%

Percentage of Patient Direct to Waiting Room

100.0%

60.0%

80.0%

20 0%

40.0%

y = -0.0018x + 73.4610.0%

20.0%

Weekly Mean Door to Doctor

250 0

CTAS 4 Weekly Mean Door to Doctor Time

200.0

250.0

150.0

0 0481 2105 5

100.0

y = -0.0481x + 2105.5

0.0

50.0

0.0

Weekly Mean Door to Doctor

200

Pre and Post January Weekly Mean Door to Doctor Team

150

200

100

150

y = -0.2203x + 139.39

50

100

y = -0.3077x + 118.250

01 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67

Pre January Post January

90th Percentile Door to Doctor

350

90th Percentile

300

350

200

250

s Ti

tle

y = -0.0487x + 2239.6100

150Axi

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0

50

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CTAS 4 Door to Doctor < 90 mins.

80.0%

Door to Doctor Time < 90 Minutes

60.0%

70.0%

40.0%

50.0%

y = 0.0003x - 10.52420.0%

30.0%

0.0%

10.0%

0.0%

CTAS 4 LOS

350

CTAS 4 Weekly Mean LOS

300

200

250

y = -0.0512x + 2335.2100

150

0

50

0

CTQ Statistical Results

Low acuity weekly statistics(door to doc and LOS)

Pre January

Post January

Delta Meansstatistically ( ) y

14th 2013y

14th 2013y

different?

CTAS 4 (mean) 132.1 110.8 21.3 YesCTAS 5 (mean) 126.7 108.3 18.4 Yes( )CTAS 4 (median) 118.8 94.5 24.3 YesCTAS 5 (median) 113.1 93.1 20 YesCTAS 4 90th percentile 240 2 217 5 22 7 YesCTAS 4 90th percentile 240.2 217.5 22.7 YesCTAS 4 90th percentile 228.5 200.6 27.9 YesCTAS 4 % of patients < 90 min 36.5% 48.4% 11.9% YesCTAS 5 % of patients < 90 min 39.7% 49.6% 9.9% YesCTAS 4 LOS 233.6 210.9 22.7 YesCTAS 5 LOS 197.5 180.6 16.9 NoCTAS 5 LOS 197.5 180.6 16.9 No

Two sample t-test at 95% confidence interval used to test results

Post Implementation Survey ResultsResults

Survey Statistical Results

Survey Question Pre mean score

Post mean score

Delta Meansstatistically different?score score different?

I was seen in triage (first assessment) in a reasonable amount of time

4.05 4.48 0.43 Yes

I was seen by a doctor in a reasonable amount of time 2 37 3 38 1 01 YI was seen by a doctor in a reasonable amount of time 2.37 3.38 1.01 Yes

I received care, and treatment in a reasonable amount of time 2.18 3.84 1.66 Yes

Throughout my visit, I (or family / friends / care giver) was kept informed about tests and treatments

2.42 3.32 0.9 Yesinformed about tests and treatments

I (or family / friends / care giver) was kept informed about tests and treatments

3.11 3.73 0.62 Yes

I (or family / friends / care giver) felt understood and cared b t b th t ff

3.39 4.1 0.71 Yesabout by the emergency staff

Throughout my Emergency Department visit (triage, registration, tests, and treatment), my pain level was managed in a timely manner

3.5 3.79 0.29 No

Staff kept me (or family / friends / care giver) informed about the next steps in care

2.88 3.69 0.81 Yes

Two sample t-test at 95% confidence interval used to test results

What is the data telling us?

“Ensuring the most rapid possible contact with a physician satisfies the desires of ED patients promotes efficiency of care and shortens lengthdesires of ED patients, promotes efficiency of care and shortens length of stay”

Leading practices in Emergency Department Patient Experience; Ontario Hospital Association (2010/2011)

• Have we impacted rapid contact with Physicians?• Does rapid contact with a Physician satisfy the desires of the p y y

patient?• Does rapid contact with a Physician promote efficiency of care

and shorten length of stay?g y

Continuous Improvement

• Team celebrated success of the work, but i th t thi i k irecognizes that this is a work in progress

• Even with the 12% improvement in low acuity patients seen by a doctor within 90 minutes, there is still work to be done

• The team still meets regularly to monitor the performance metric statistics

• The team is moving into a 2nd phase with a focus on high acuity patients

Some Encouraging Words

• “Even when it is busy, there is a sense that we can manage.”– ED RN

• "The changes in the department have made a huge difference, for patients and morale.“

– ED RNED RN

• “Now there are always patients ready for me to see, instead of waiting for patients to be brought in from the waiting room.“

ED Ph i i– ED Physician

• “I am from Truro and have been to emergency rooms many times. This one is undoubtedly the fastest, friendliest and best one ever! Thanks for all the help and care!”

– Patient Survey Comment

• “This was the fastest time to see a doctor, the doctor was very professional.This was the fastest time to see a doctor, the doctor was very professional. Rate him a 10 out of 10.”

– Patient Survey Comment