Copyright © 2002‐2013 Urgent Matters 1

EMERGENCY DEPARTMENT CARE REDESIGN USING THE NOVEL RAPID PROCESS OPTIMIZATION (RPO) METHODOLOGY UNIVERSITY OF COLORADO HOSPITAL

Publication Year: 2013

Summary:

A novel process redesign methodology that uses data to inform solutions, reduces variability, eliminates waste and non-value add activities, optimizes revenue and focuses on metrics.

Hospital: University of Colorado Hospital Location: Aurora, CO Contact: Jennifer L. Wiler, MD, MBA, FACEP

Jennifer.wiler@ucdenver.edu

Category:

A: Arrival

B: Bed Placement

C: Clinician Initial Evaluation & Throughput

D: Disposition

E: Exit from the ED

Key Words:

Communications Consults Continuity of Care Patient Satisfaction

Wait Times

Hospital Metrics: Annual ED Volume: 75,000

Hospital Beds: 550

Ownership: University of Colorado Health

Trauma Level: 2

Teaching Status: Yes

Tools Provided:

Hahnemann University Hospital Triage Plan

Tools Provided:

Rapid Process Optimization Methodology

New ED Process

Post-Redesign Implementation Metrics

Heart Failure Treatment Pathway

Clinical Areas Affected:

Ancillary Departments Consult Services Emergency Department Inpatient Units

Staff Involved:

Administrators

Case Management

Clerks

ED Staff

IT Staff

Nurses

Pharmacists

Physicians

Registration Staff

Copyright © 2002‐2013 Urgent Matters 2

Innovation Just prior to the implementation of our new ED patient flow, our ED had 150 hours of ambulance diversion, over 10,000 hours of ED boarding, an average ED total length of stay 355 minutes, average door to doctor time of 67 minutes, and poor staff and faculty morale. Before the implementation of the ED process redesign project, to address capacity issues and boarding, we had expanded ED treatment spaces to include 21 hallway beds and 11 beds in a closed clinic adjacent to the ED. A new and significantly larger ED was planned for and there was a desire to use this opportunity to redesign the care process. Innovation Implementation Dr. Richard Zane, Chair, University of Colorado, charged our physician and nursing leadership to completely redesign the way that emergency care was delivered, coincident with our planned move into a new Emergency Department (ED) space in June 2013. The rules of engagement were that all decisions about process innovations were to be patient-centered, data-driven, and utilize a novel methodology for process improvement; the Rapid Process Optimization (RPO) Methodology, specifically designed for this engagement. The Process Improvement Steering Committee was created to lead this ED flow redesign. The team was comprised of process improvement, nursing and physician leadership. All team members contributed meaningfully to this endeavor. Co-Chairs: Derek Birznieks, MBA, Director of Process Improvement University of Colorado Hospital Jennifer Wiler, MD, MBA, FACEP, Vice Chair, Quality, Safety & Process Improvement; Assistant Professor, Department of Emergency Medicine Rob Leeret, RN Director of Emergency Services and Capacity Management Committee: April Koehler, RN, Clinical Nurse Manager, Emergency Services Kelly Bookman, MD, FACEP, Associate Medical Director, Emergency Services, Associate Professor, Department of Emergency Medicine Justin Emerick, Process Improvement Consultant Robin Scott, RN, Clinical Nurse Specialist, Emergency Services Stephanie Prevost, RN, Associate Nurse Manager, Emergency Services Brandi Schimpf, RN, Clinical Nurse Educator, Emergency Services.

Background: Many healthcare institutions have utilized various methods to engage faculty and staff in process redesign including LEAN and 6-sigma. These methodologies require extensive training (on-boarding) and non-stakeholder staff support to maintain as well as significant time to develop and implement. Due to the timeline of our already planned move to a new ED space, we needed to redesign care in 6-8 months, whereas, LEAN or 6-sigma would have taken at least 3 years to execute all of the modules and processes. Objectives: To create a novel process redesign methodology that uses data to inform solutions, reduces variability, eliminates waste and non-value add activities, optimizes revenue and focuses on metrics, but requires limited formal training (on boarding) and limited non-stakeholder staff support to maintain. Methods: We devised the RPO methodology which relies on five distinct guiding principles or pillars; the "5 E's"

Evaluate, detailed assessment of current state processes and productivity; Engage, task and role analysis including human resource pairing and matching; Establish, rigorous and comprehensive pre-work with structured analytics; Evolve ("rapid process modules" [RPM]) to design ideal and future state); and Execute (proof of concept using progressive high-fidelity simulations, reassessment, and execution of

redesigned future state).

The foundation of the methodology is based on the tenets of change management, central discipline but local control, integrated rational and economic use of appropriate process optimization tools, focused and paired collaboration of process optimization and content experts, structured conceptual evaluation with quantifiable and actionable remediation, franchise replication of RPO with customization to service line and/or function, system wide electronic health record optimization and central governance. The primary aim is for the process to be patient centered and data driven.

Copyright © 2002‐2013 Urgent Matters 3

These included adding a provider in triage (physician assistant) during peak arrival hours, providing observation care in ED beds, expanding our clinical space by using hall beds and ad hoc use of other clinical care areas including other clinics' space. "Using the RPM methodology we convened multidisciplinary frontline staff (stakeholder) groups to:

Review current best practice literature as RPM pre-work. Review and validate current state process maps developed by the Process Improvement teams' observations. Develop future state recommendations based on parameters (eg. budget neutral). Present recommendations to senior leadership multidisciplinary stakeholders for approval to move to testing. Testing (table top and simulation) of recommended process. Process modifications based on testing, when appropriate.

Finally, large scale training of staff on new process occurred by multidisciplinary teams and PI champions. Staff engagement included nurses, techs, registrars, EMS, respiratory, ECG techs, housekeeping, transport, radiology, laboratory, case management, social work, behavioral health, and numerous medical services (eg. neurology, stroke, hospitalists, trauma, general surgery, orthopedics, radiology, pathology, etc).

New processes implemented utilizing the RPM methodology included:

Elimination of triage, and implementation of a Pivot Team; Launch of a physician in Intake to initiate testing, to make decisions about placement in ED (acute vs.

Supertrack) or to discharge after full assessment; and to eliminate ad hoc triage out system Expansion of fast track to Supertrack with utilization of internal waiting room area; Expansion of scribe program; Implementation of evidence-based care pathways in order to standardize care and improve outcomes Implementation of a point of care testing program Establishment of a 16 bed Clinical Decision Unit (CDU) and observation care service line; Establishment of an ED Call Center; Launch of a 24 hour retail pharmacy in the ED with default e-prescribing ; Refinement of Epic electronic health system; and Job righting, Assuring that specific tasks are assigned to the appropriate level of healthcare provider or

employee (i.e., transporters moving patients instead of ED technicians). Timeline/ Results It was clear that we needed a complete process redesign. Specifically, we needed frontline staff re-engagement and a new vision of care delivery that placed the patient at the center of our clinical operations. We had attempted limited, disjointed and unsuccessful changes in the past, which further fragmented department care delivery. We have performed eight RPMs (front-end, core, back-end, case management, radiology, laboratory, transport/ancillary services, pharmacy) as part of our process redesign coincident with moving into a new emergency department. This process redesign methodology is currently being utilized to train units across the hospital beyond emergency medicine. From the initiation of planning to the implementation date it was approximately 8 months. The training and education of staff and physicians took place over 2 months prior to implementation in addition to participation in the RPM's. Go live was done in a "big bang" fashion on the day we moved into a new ED space.

Decreased door-to-physician time from average 67 minutes to an average of 15 minutes. Increased patient satisfaction scores from 79.3 to 85.9 (raising UCH, from the 17th percentile Press Ganey

ranking to 72nd percentile %). Decreased LWBS from 4% to 0.5%. Decreased discharged patient LOS by 53 minutes (from 244 minutes to 191 minutes).

Copyright © 2002‐2013 Urgent Matters 4

Decreased admitted patient LOS by 36 minutes (from 246 minutes to 201 minutes). Decreased overall LOS by 2.25 hours (from 355 minutes to 220 minutes). Physician intake discharge rate is 36% on average. Supertrack manages 16% of overall volume during peak hours.

Cost/Benefit Analysis The entire project was required to be budget neutral for the hospital. Utilizing activity based cost accounting principles; we defined the ideal standard work description (including work effort) for the major staff entities vs. current state job functions. This reallocation of resources allowed us to address mismatches of tasks being performed by higher cost positions. For example, we noted that most transports were being performed by ED nurses and technicians, only 500 transports/month being done by ED transporters. With "job righting" as part of the process redesign, we eliminated the task of transport from nursing staff, allowing them to increase their focus on nursing activities which necessarily increased nursing productivity without an increased need for hiring. Due to the increased nursing productivity, we were able to shift FTE (full time equivalent) positions to increase the number of ED transporters. Post implementation of this change, our nursing rations expanded from 1:4 to 1:4.5 with over 4000 transports/month being done only by ED transport. Activity based cost accounting principles including cost savings related to improved throughput were also leveraged for the establishment of other new ED programs (i.e., CDU, point of care testing, scribe program expansion). Advice and Lessons Learned

1. Create a burning platform as to why change is necessary. 2. Garner support from frontline staff leaders / culture-makers, and identify and embrace early adopters. 3. Over-communicate planned changes with frontline staff and celebrate early successes.

Sustainability This journey is the beginning, not the end, for our department. Our Process Improvement Steering Committee is committed to ongoing practice assessment and re-evaluation. The resources needed for sustainability are constant engagement of frontline staff in local environment assessment, the creation of a "just culture" that supports highlighting of errors and potential errors allowing for systems corrections, continuing education of the staff to prevent mission creep, steady direct messaging with "boots on the ground" to address issues real time and to identify inappropriate process modifications, and the identification of future RPM's to tackle new and ongoing process issues in order to optimize our healthcare delivery model. We have embedded process improvement specialists into the ED operations infrastructure. Tools to Download

Rapid Process Optimization Methodology New ED Process Post-Redesign Implementation Metrics Heart Failure Treatment Pathway

RPMsRapid Process

Modules to designideal future state

Proof of conceptusing progressive

high-fidelitysimulations,

reassessment, andexecution of

redesigned futurestate

Rapid Process Optimization (RPO) Methodology

Detailed assessmentof current stateprocesses andproductivity

Task and roleanalysis includinghuman resource

pairing andmatching

Rigorous andcomprehensive pre-

work withstructured analytics

Central Discipline, Local Control

Integrated rational and economic use of appropriate process optimization tools

Focused & paired collaboration of process optimization and content experts

Structured, conceptual evaluation with quantifiable & actionable remediation,including table-top to live exercises utilizing substantive data

Gate Gate Gate

Franchise replication of RPO with customization to service line and/or function

System-Wide EMR optimization

Draft v5Birznieks, Zane10-9-12

Governance, command & control

Gate

Evaluate Engage Establish Evolve Execute

Change Management

Patient Centered, Data Driven

Operational / Clinical Area of Concentration

Attending MD tells Scribe to document a full note for the encounter and dictates MDM and disposition.

Scribe: moves PT from intake room to internal waiting and turns Pt yellow in Epic (meaning MD approves DC)

Intake Tech moves Pt to internal waiting room and says, "The RN will be over shortly to give you your discharge papers and prescriptions."RXs are e-prescribed to ED pharmacy except narcotics which will print at SuperTrack printer.

Intake Tech collects narcotic script and gives it to the Intake MD for signature, then gives Rx to patient.

SuperTrack RN is screening the board and is queued by new patient in internal waiting room who is yellow status – Pt requires DC paperwork (if Pt requires narcotic Rx Pt should have it in hand).SuperTrack RN tells Pt, “follow the signs to the discharge desk”, and points Pt in the right direction.

Discharge CTA………….

Pt is appropriate for Discharge if requires no testing, no intervention, and no medication.Pt is appropriate for SuperTrack - if answers no to SuperTrack Appropriateness Assessment Tool questions, AND MD feels that Pt is not "complicated".PT is appropriate for Main ED Bed if: language barrier, pelvic exam, blood work, behavioral issue, likely to need assessment >2hrs.

Pt Enters ED

Security

Pivot

PodResuscitation/Exam Room

Pod

Intake

Security: “Are you here to be seen?” If yes, “Please take out your ID if you have one and proceed to the ‘Start Here’ sign.”

Security checks family in, gives badges, and directs family to Ambassador.

Pivot Tech: “Right this way mam/sir. Have you been here before? What is your name, SS# and date of birth?”

(If Pt cannot say their name or doesn’t want to say SS# aloud, use dry erase board)

Pivot Tech: “What brings you in today?”

CTA: Listens to patients name and SS# and inputs into EPIC (quick reg)

CTA: Enters chief complaint into EPIC

CTA or Front End Tech: Gets armband from printer, verifies patient information with 2 identifiers and puts band on patient

Pivot Tech: Uses Pivot RN Assessment Pathway

Pt goes straight back to Pod if one of the following is true: Very sickRequires immediate EKGAll 4 intake rooms are full AND there open beds in a podBehavioral issue that would impede rapid intake assessment

If patient needs to go straight back (SICK) to room (or if no Intake Room is available):Pivot RN: calls Flow RN: “I need a bed for Ms/Mr (name) RED (sick) or GREEN (not sick)”

Pivot Tech: makes overhead page (FOR REDS ONLY): “New Pt in room #” and takes patient back to the appropriate room.

CTA or Pivot Tech: Drags and drops patient into appropriate intake room in Epic.

Front End Tech: Walks Pt to Intake Room and says: “The provider will be here to see you shortly, this outlines the process for the care that you will receive today.” (points to care process sign on wall) Tech Pushes cancel button on the call light system, Then presses the pink “Patient Arrived” button.

If Pt cannot say their name or doesn’t want to say SS# aloud, use dry erase board.

Pt goes straight back to Pod if: very sick; requires immediate EKG; all 4 intake rooms are full AND there open beds in the pod; behavioral issue that would impede rapid intake assessment.

See “Exam Room” steps below.Initiate Critical Care Protocols

*INTAKE ROOM CLEAN - if grossly dirty Intake Tech calls for housekeeping to clean, otherwise Intake Chair is wiped down by Intake Tech.

MD Enters Room WITH Scribe and possibly Tech (or Tech may enter alone):

MD: Enters intake room and presses the cancel button on the call light system and says “Hello, I am Doctor (name), this is (Tech name) our technician, and this is (scribe name) our Scribe. I am going to do a brief initial assessment. I will decide if you need further testing and will send you to another part of the Emergency Department to continue your care process, where you will tell another provider about your problem in more detail. Can you tell me what brings you in today?”

Front End Tech: Gets vitals which are entered into EPIC by Tech or Scribe

MD: Does medical screening exam to differentiate immediate discharge / SuperTrack / Main ED Bed (Should use SuperTrack Assessment Tool). This assessment should take 3-5 minutes and be documented into EPIC by Scribe

MD: Tells Intake Tech Pt disposition (can use phone)

Main ED Dispo: Intake Tech: Calls Flow RN. “Flow RN, this is Intake Tech. I need a Main ED Bed for Mr/Ms (name).” Tech presses green “Room Available button” when leaving intake rooms and takes patient to assigned room and presses “Patient Arrival” call button. Tech asks Pt to get undressed, hands them gown from bed and says: “Please put your belongings in bag (on bed) and if you have to urinate, please collect a specimen in this cup in case your care team needs a sample,” and finds an appropriate Pod team member for a verbal hand-off.Intake Tech: Drags and drops patient into appropriate room in Epic.

SuperTrack Dispo: Intake Tech: Walks Pt to ST / Internal Waiting, finds a ST team member for a verbal hand-off, and returns to Intake.

*Discharge From Intake Dispo - Attending MD tells Scribe to document a full note for the encounter and dictates MDM and disposition.Scribe: moves PT from intake room to internal waiting and turns Pt yellow in Epic (meaning MD approves DC)Intake Tech moves Pt to internal waiting room and says, "The RN will be over shortly to give you your discharge papers and prescriptions."RXs are e-prescribed to ED pharmacy except narcotics which will print at SuperTrack printer.Intake Tech collects narcotic script and gives it to the Intake MD for signature, then gives Rx to patient.SuperTrack RN is screening the board and is queued by new patient in internal waiting room who is yellow status – Pt requires DC paperwork (if Pt requires narcotic Rx Pt should have it in hand).SuperTrack RN tells Pt, “follow the signs to the discharge desk”, and points Pt in the right direction.

**INTAKE ROOM CLEAN - if grossly dirty Intake Tech calls for housekeeping to clean, otherwise Intake Chair is wiped down by Intake Tech.

New ED Process

Ambassador

If Pt is with Family:

Ambassador will orient the family as to where their family member is in the department or to the family waiting area.

*DISCHARGE FROM INTAKE

Family Waiting Area

Family

IF Labor and Delivery:TBD with L&D Pathway

Disposition:Pod

Disposition:SuperTrack

Disposition:Discharge

Internal Waiting

Super TrackPod Exam

Room

Scribe moves PT from intake room to an open SuperTrack bed in Epic.

Front End Tech moves Pt to SuperTrack, pressing the green “Room Available button” when leaving intake room.

-IF Pt requires exposed limb Tech gives Pt a gown and says, “Please change into this gown and the PA will be in to see you shortly.”-IF Pt requires x-ray, Pt is taken to SuperTrack radiology where Tech leaves Pt and says, “Once your x-rays have been taken you will be brought back to the results waiting area until your results are ready at which point we will come and get you.” All Pts, after SuperTrack x-ray, go to internal waiting room until their image is read and a treatment plan, or disposition plan is made.-IF Pt requires a urine sample, ST RN gives urine cup to Pt, shows them to restroom, and says, “Please return to bed (number) when you have finished filling the cup, we will come to get the specimen so that we can get your tests going as quickly as possible.”

Front End Tech finds the ST PA or a ST Tech and verbally hands off Pt.All new Pts placed in SuperTrack area or internal waiting area is to be seen and evaluated by ST RN and PA except for Pts discharged from intake (Yellowed by intake attending).

IF Pt requires procedure:PA notifies Tech of what procedure is planned Tech gathers all supplies necessary for procedure and if wound requires cleaning Tech performs cleaning, or if Pt requires splint Tech preforms splint.

IF during PA eval it is determined that Pt has higher resource needs (eg. fracture dislocation requiring reduction) Pt is immediately transferred to Pod: ST Tech calls Flow RN to make new bed assignment, then calls Pod MD for hand-off/transfer of care.

When Pt is Discharged from SuperTrack (or anywhere) if able to walk Pt goes by themselves to DC, if unable to walk Pt is wheeled out by volunteer (if available) or Tech.

GOAL - Total LOS of SuperTrack patient <= 1.5 hours

Front End Tech: Wheels Pt to assigned Main ED Room. Upon arrival in Main ED:

Front End Tech: Presses “Patient Arrival” call button

Front End Tech: Asks Pt to get undressed, hands them gown from bed and says: “Please put your belongings in bag (on bed) and if you have to urinate, please collect a specimen in this cup in case your care team needs a sample.”

Front End Tech: Notifies Main ED care team that patient has arrived (notifies Pod Tech that Pt has arrived and is in Room). IF Pt came directly from Pivot and is RED, Tech also makes overhead page announcing arrival of Red patient with Room #. Tech Returns to front.

Care Team (Main Tech, RN, MD): Take over care process in Main

Main MD: “I know that you have seen other members of our team already. I am going to be your main doctor today.”

GOAL - Total LOS of Main ED patient <= 3.5 hours

Table 2: Post University of Colorado Process Redesign Implementation Metric

Post-Implementation

(Average)Pre vs post 6mn

varianceChange

Daily Census 239 195 22%Overall Length of Stay

(minutes) 220.5 354.6 -38%Discharge Length of Stay

(minutes)* 191.6 244.2 -22%Admit Length of Stay

(minutes)* 201.1 246.0 -18%Door to Provider Time 14.5 67 -78%

Left Without Being Seen 0.52% 4% -87%

SCHOOL OF MEDICINE DEPARTMENT OF EMERGENCY MEDICINE

EMERGENCY DEPARTMENT

Approved: Heart Failure Service; L Allen MD, P Buttrick MD, G Wolfel MD 2/26/2013 EDCQI Committee 3/8/2013

Hospitalist QI and DOMQI Reviewed 2/26/2013

“This quality improvement document is to be maintained solely within the institution and may not be released to any third par ty without written permission from the department, hospital, and university legal counsel.”

Heart Failure (HF): Treatment Pathway

Yes

No

Diagnose of HF Made: Symptoms consistent with Heart Failure

No

Yes

Yes No

Yes

No

Reassess in 1-2 hours Have presenting symptoms improved?

Call Amanda Nenaber RN, CNS HF Program (8-7367)

(She will track 30-day readmits)

Please leave message if no answer

Moderate / Severe HF Exacerbation?

Any of the following:

BNP >500 / 1.5x baseline

Pulmonary edema, hypoxia

Relative hypotension (SBP<100 OR lower than patient’s usual in Flowsheet Vitals)

New elevated Cr/BUN, LFTs

New ECG changes or troponin >0.5

Requires inotrope or IV vasodilator

History of end stage renal disease

High risk condition, including: o LVAD o Heart transplant

Mild HF Exacerbation? No moderate or severe risk factors

ADMIT to ED CDU

Use “CDU HF ORDERSET” to give: o Oxygen o Furosemide IV (with evidence of volume overload)

Double dose of oral diuretics OR, If diuretic naive, 20 mg IV, unless CR >2.5 then give 40 mg

IV o Consider ordering home PO meds (if not already taken)

Call Amanda Nenaber 8-7367 (if not notified per above)

ADMIT IF does NOT require ICU or Stepdown Admission, then admit to:

Heart Failure/Heart Transplant Service: On transplant list, or LVAD patient, or seen in clinic by a HF attending (Allen, Ambardekar, Brieke, Lindenfeld, Shakar, Wolfel)

Admit Cardiology: New onset HF (regardless of age), or followed in cards clinic, or history of heart disease

Admit ACE: >70 years of age

Admit Medicine/HTT/HMS: All other patients Order:

Oxygen

Furosemide IV o Double dose of oral diuretics or, if diuretic naive, 20 mg

IV, unless CR >2.5, then give 40 mg IV

Does patient have new onset heart failure?

Redose IV diuretics – DOUBLE DOSE of IV furosemide previously given

Consider Discharge PLEASE USE HF DISCHARGE

ORDER SETS

Has patient been hospitalized at any hospital for HF within the last 30 days?

Reassess in 1-2 hours Have presenting symptoms improved?