When Healthcare Process meets Technology
Where use cases drive solution success- ED Patient Flows
The Healthcare Process
Alan was in charge of the Hospital lab. His facility tested samples received from various parts of the hospital, other community hospitals as well as the ED. The ED was a short walk in the same wing of the hospital. Most samples came through the chute though on some occasions, some that had priority, were hand delivered. Alan could see the time when samples were taken in the ED and labeled for dispatch to the lab on a custom desktop application that received feeds from the hospital EMR.
Alan looked at the monitor- something did not seem quite right. The monitor indicated around 17 or 18 samples taken in the ED anywhere between 27 to 117 minutes ago. But none of those samples had reached his Lab. He picked up the phone to talk to the Charge Nurse in the ED but could not connect. Concerned, he walked over to the ED to have a conversation with the ED charge nurse. The samples were in the ED labeled but not shipped! He would now receive a whole batch of samples.
The ED was running at capacity with an overflow of patients in the Waiting room. Things were breaking down. The triage-assessment- lab value stream had lean waste written all over it:
There were transport issues.
Patients, physician and the floor nurses were waiting in their rooms for Lab results to complete- the lab was waiting for the samples to arrive and when they did, they arrived in a batch- there was no priority- the delays in the lab testing were creating a wait issue for admitted patients and an inventory issue in the waiting room.
Some samples were simply dated, fresh samples had to be taken- over-processing as well as over production waste.
There was motion waste.
The ED was running at 100 percent- traditional flow theories (fluid dynamics, queuing) suggest that around 80-85% of service capacity things will start to fall apart.
Can this process be better managed? Are there interventions in the process that can smooth the flow? Is technology the answer?
"We do not want more technology" care teams are inundated and tired with all the technology thrown at theme. Stories abound on adoption failures.
Technology fatigue sets in- technology is not the answer- solutions are and solutions need to enable, engage and empower users rather than get in the way or intrude.
In healthcare as in any other vertical the issue is how seamlessly and how unobtrusively a solution enables a use case, a workflow or a process in healthcare. The smoother and friction free the fit the more likely that the solution will be adopted. Understanding the process and the participants in the process- how they communicate, collaborate, coordinate or synchronize their activities will provide answers to use cases- adoption models- systemic integration needed to create an ideal solution.
But first one needs to start with an understanding of process and process performance.Metrics are a good indicator of process performance.
Where is the start point:
Identify service lines in an acute hospital that have a large volume of patients and the Case Mix index associated to these service lines. The Case Mix Index gives an idea of profitable and unprofitable service lines. Dig deeper at the HRRP numbers- readmission reduction- readmission penalties point to service lines that are non-compliant to required metrics. Connect the dots to outcome scores, clinical process of care domain scores and patient experience score and a high level picture of process performance begins to emerge. There are processes that need a closer look.
Emergency Department (ED) Workflows:
The ED in most hospitals is an entry point for in-patients- anywhere from 35% to 70% of in-patients flow in through the ED. In some hospitals electives also flow through the ED before being admitted. Wait times in an ED flash across bill boards and web sites. Dig deeper and ED metrics tell a story- for admitted and discharged patients:
OP-18b: Length of stay, OP-20: Door to diagnostics
OP22: Left without being seen (# of patients)
There are National and State averages for these metrics in the US. Some National averages:
Door to Diagnostics - 24 minutes
Time before admission- 4 hours 34 minutes
Transfer/ Boarding Time – 1 hour 37 minutes
Left without being seen – 1%
These metrics tell one part of the story. Dig a little deeper into the clinical process to get the full story. There are two categories of patients walk in patients and those that come through the Ambulance bay. Patients go through four stages in the ED:
Check In - the initial Triage
Assessment - the diagnosis
Intervention - the treatment
Discharge or admit
What was the arrival to bed time for the ambulance patients?
What was the triage time for walk-ins and the time from arrival to bed for these patients?
What was the door to doctor time?
Intervention, Treatment and Discharge:
There are 4 categories of patients (actually 5) with different severity levels.
ES1 – Trauma cases- or the highest severity level. This category of patients get prompt attention are stabilized and then moved to other parts of the hospital- the ICU in most cases.
ES2: Patients with major injuries.
ES3: Patients with minor injuries.
ES4: Usually the Fast Track, see and treat patients
For these patients ES1-4, the EMR can provide a number of interesting metrics that reflect underlying process performance:
Average Length of stay,
The door to doctor time,
Stat order response time,
The average time for lab order to collect and collect to lab receipt, wait time for lab results, time spent responding to lab results,
Drug reconciliation times,
Disposition to discharge times,
Time to clean room upon placement of a discharge order,
Nurse response time to patient monitor alarms,
Percentage of false alarms.
Observation and Shadowing:
Create a snapshot view of each stage of the ED process- from Patient Admission, Diagnosis, Intervention and Discharge followed by a walk through helps in building a hypothesis of the key process to be investigated, the stakeholders to be shadowed and the events that need to be tracked.
There are key resources inside the ED that need to be shadowed across multiple shifts for a few days- Physician, Charge Nurse, Triage Nurse, EVS, ED Hospitalist, Nurse supervisor, Patient Access Representative, Patient Advocate, Scribes, Social Worker, Case Manager, Transportation, Phlebotomists, Communication clerk (switchboard operators), and a few outside of the ED- Bed management, ICU, Pharmacist, Diagnostics, Imaging, Floor charge nurses.
Observations can be complex- issues observed need to be repeatable, should recur across multiple shifts, should point to process issues rather than a particular person issue. Observers need to examine the events and process friction through lean filters to understand lean waste and compounding impacts of the waste upstream or downstream:
In an ED events are fast paced; sometimes an event starts and is interrupted by another event, before the first event can be acted upon.
A physician may be entering stat orders when a nurse walks in to discuss a patient situation or a radiologist calls to discuss a patient situation. Events in an ED have triggers:
An event may get triggered by an observation of a patient condition or the vitals,
An event may get triggered through a memory task - physicians enter patient status and stat orders in the EMR after making rounds either through memory or notes on paper
An event could be triggered through a collaboration between a physician, a nurse, a specialist, pharmacist or the lab.
An event could be triggered as a result of a diagnostic image or a Lab result
Delays in responding to events:
Healthcare resources are mobile- most of the time. Information arrives sometimes via E-Mails or is recorded in an EMR by a physician stat order, a lab result or a diagnostic image with no notifications to the mobile recipient. This is passive communication and a lack of notification makes this open loop in nature. There are no escalations if the event is not acted upon in a timely fashion, sometimes the ball gets dropped but in most cases delays set in.
Therein lies the problem, when an ED runs at full capacity memory events and open loop activities create artificial slowdowns. ED problems can be categorized into five distinct areas:
Most operational issues are driven by lack of coordination, synchronization of activities and the open loop communications in the ED. A patient was wheeled into imaging, but refused to get screened until a physician had personally examined her. The transport technician wheeled the patient back to her room but did not inform the physician and no updates were made to the EMR. The physician assumed the patient had been imaged and would wait for an update from imaging in the EMR. Two hours later the patient created a scene- and that was when the physician realized that she had not yet had her images taken.
Batching creates avoidable waste. Physicians batch their orders after examining patients - inherently introducing delays to actions for the first patient seen. If there is a drug issue the situation gets compounded with the pharmacist attempting to get approval from the physician. Notifications with patient context and approvals through Mobile IT access on smartphones could solve this problem.
Nurses too often batch discharges- sometimes creating defects. Discharge notes mix-ups have been reported in some facilities. Patients are discharged but at busy times nurses tend to forget to update the EMR about the discharge. EVS assumes a patient is still in the room and the room remains unusable while patients in the lobby wait for admit.
Collaboration amongst the care teams both inside and outside of the ED has challenges- if it involves resources outside the ED - transfers or admits- there are other issues. In one situation the ICU received a notification for a patient admit from the ED. The charge nurse in the ICU made several attempts to get the patient transferred, however there was breakdown in the collaboration between the transport and the two charge nurses. The ED could not locate a spare gurney but there was no notification to that effect. Eventually the ICU charge nurse had to locate a gurney and wheel the patient to the ICU.
A big issue in ED's as in other parts of the hospital is locating people and things. Nurses- both floor and charge nurses, spend a lot of time trying to locate monitors and diagnostic equipment such as charge pumps or an EKG machine or other diagnostic devices. Locating people even in a closed space such as an ED can be a challenge.
Bed Management- as anyone in a hospital will tell, is a huge issue. The true status of available beds, clean rooms, patient transfers can be a nightmare even with the best EMR technology.
The issue more often than not is people and process, solutions need to take this into account and there are ways and means and solutions that can create appropriate notification to mitigate some of this bed management challenges.
A customer saw an improved bed utilization of over 400 minutes a day by better using the technology acquired earlier on just one use case- a huge expand opportunity of the solution vendor.
Shadowing exercise to capture events and the friction in the process:
Capturing the events at various stages of a patients journey in the ED allows one to understand use cases where process change or technology insertion can help mitigate the operational inefficiency or lean waste:
The shadowing exercise ties the event to the issues- the collaboration, coordination, communication and synchronization of activities, the breakdown expectation during peak loads as a result of open loop, passive process steps, the technologies used and the issues with their usage.
Can Technology meet process?
There is no shortage of technology in healthcare, in fact one can find similar technologies from more than one provider in use. Vendors sell their technologies but leave it to the customer to integrate that technology into the work environment and the process. When things don't work there is always finger pointing.
Healthcare customers require solutions from vendors that work with each other are seamless in the work process and have little learning curve.
Case in hand - nurses, physicians, techs are provided with wireless phones. At the beginning of each shift phones are allotted. In some hospitals the communication clerk lists the extension on a board- black-board or digital- against the resource to which the phone has been allotted. She then prints a list of extension and faxes this to various parts of the hospital. If one wants to reach a nurse one must first identify the extension and then make a call. Would it not be better to have a single permanent number reach for each resource? A smartphone with a directory and with a little systems integration on the Collaboration software the care teams security badge could be scanned on the phone to register the extension to the permanent number.
How do you make open loop, passive processes into active process? Technology from Vocera/Extension (#Vocera) can provide smart notifications with integration to the EMR and other clinical systems- and perhaps some scripting. So nurses can be notified about stat orders and can intervene; physicians and pharmacists can collaborate through text, video or even E Mail. With mobile IT access orders can be entered at the patient bed eliminating the need for batch updates.
Bed management huddles and other meetings can be done through virtual collaboration solutions.
Real time location technologies are use case or application specific. Applications determine the underlying wireless technology- Is it certainty based- infant tracking; peri-operative workflows, ED workflows; limited certainty based - asset security, asset location; or calculation based through triangulation such as way-finding. Wireless technologies can be LF, Gen2 Infra red, Bluetooth Low energy, UHF Wifi just to name a few. A look at the closet design would also indicate failure modes and applications that could potentially fail if the switches fail.
Shadowing the participants in some of the key processes help identify fairly interesting use cases- some use cases where existing solutions can be deployed, some use cases that may need new technologies and some creative systems integration.
When the solution enables, engages and empowers the participants there will be adoption and a much desired land and expand for technology. At that moment technology meets the process enables, engages and empowers the workforce, transforms patient experience and workforce productivity.
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