Simulation Presentation to DesignMay 21, 2008

Agenda

Simulation Process Redesign Sample Emergency Project Clients

Simulation – What is it?

Mathematical representation of real life Model generation on simulation software Queuing theory Randomization and variation Input process information Outcome statistics Scenario model to compare outcomes

Simulation – Project Steps

Collect data Define current process Develop model of current process Compare model outcomes to real-life Define changes Develop scenario models Compare scenario to model outcomes

Simulation - Data Volumes

Average and Peak Daily Visits, Arrival by Hour Types

Walk-In/Ambulance, Acuity, Discharge/Admit/Transfer Activity Times

Triage, Evaluation, Tests, Disposition Waiting Times

Test Results, Renege/Leave Without Being Seen Locations

Triage, Beds Staff Schedule

Physician, Nurse, Tech, Clerk, Registration

Simulation - Patient Volume

Daily average 157.8 visits in 2007 Monthly range from 147.0 to 163.6

Simulation - Patient Arrival

Pattern of arrival by hour

Simulation - Locations

Current 3 Triage 5 Fast Track 30 Beds 12 Overflow beds

Triage Go to BedClerk Enter

OrdersNurse Eval

Pt

Order Lab?

Lab

Disposition DischargeAdmission

Yes

Order Xray?

Radiology

Order Other?

Other Procedure

Order Med?

Medication

No No No No

Yes Yes Yes

Ambulance

Wait For All Results

Leave ED

Walk-In

RegistrationPhys Eval

Pt

Transfer

Emergency Process

Emergency Model

Current Model LOS OutcomesLOS Hours Current LOS

Minimum 1.21

Average 3.98

75%ile 4.84

90%ile 6.14

Maximum 14.24

Process Redesign

Insight Strategies, Inc. - Lean Method

Patient arrives Name/DOB/Chief complaintWRIST BAND/LABELS/FACE SHEET PRINTED

Wrist band put on patientInfo placed into slot for

Triage Nurse by Admitting Staff

Patient waits for TriageSent to waiting room

Triage Nurse evaluating patients

Triage nurse determines which waiting patient is next

most important(reviews chart/views

patient)

Triage Nurse takes patient to Triage room

Tiage Nurse does “Triage”Patient sent to Registration/

RoomPT Registration completes

registrationPatient sent to waiting room

RN walks chart back

Patient waits in waiting room

Waiting room patients assessed continually?

(visually assessed when someone goes to waiting

room)

Rn (midnight) or Tech take patient back to room/patient

undressed/placed in bed

Tech or RN erases name off board

There is not a clear process to

determine when a room is available

Patient waits

Charge RN places RN/doc charts into appropriate rack(chart is separated into two)

RN gets RN notes and goes to the room

How does Nurse know there is a

patient/chart waiting?

RN starts IV/gets urine/draws blood for labs (what

is done is driven by protocol)

Dip UA and/or HCG done by RN

RN walks other specimens to tube system

RN walks UA and/or HCG to test area

ED Current Process

Patient waits

Doc gets chartRN gets UA/HCG tests from

PYXIS

RN walks blood/urine to P.O.C. room

Tech runs test

Tech sends specimens to lab

Tech finds chart & puts results on chart

Tech tells secretary HCG results

Secretary enters results in computer

Doc transfers info from triage form to ED template

Doc reviews patient info

Doc enters patient room and sees patient

Doc returns to desk to document

Patient waits

Doc’s orders and chart are taken to secretary

Secretary enters ancillary orders into Affinity

Secretary enters nurses orders into RN chart rack

Secretary writes Radiology “wet read” form

Tech goes to RN chart to get orders

RN goes to RN chart to get orders

Tech does tech orders

RN does RN orders

Radiology does exams

All services compete for the patient at this point...minimal

cross functional-awareness/coordination

Lab does tests

Patient taken for imaging procedures

Imaging informs RN pt is going for test

Patient waits for results

RN continually evaluates patient status

Results are transmitted (fax or printer)

Results are placed on chart by ?

Secretary does “print screen” of all orders

Screen print on chart checked off as results come

back

Is there an active process for monitoring

outstanding tests/results?

Chart (by?) placed up for disposition in Doc’s rack

? Writes Disposition on white board patient name

Is there an active process for monitoring progress?

Who is “?” ?

Doctor gets completed chart from rack and reviews

Can patient be dispoed ?

Doctor reviews decision with patient

YESDoctor writes discharge

ordersDoctor takes charts to rack (It is placed standing up)

ADD ONS

PATIENT WAITS

NO

Doc writes new orders

PATIENT WAITS

RN gets Med orders/Lab/Imaging

Secretary gets lab orders

Disposition Alternatives

HOME

ADMIT to Hospital

TRANSFERS

RN types up discharge instructions on ERIC user

and print

Educate patient with instructions...last vitals,

Q&A

RN helps patient dress/prepare to leave

Arrange for ride if necessary

Call Dr. “X” for admit“Doc for admit” gets written

Give orders to secretarySecretary prints face sheet

& confirms/reconfirms insurance

PATIENT WAITS

Secretary calls Doc Re: Admit

Secretary calls doc every 15 minutes

Doc calls back and is connected to ER Doc

ER doc writes any orders

Doc writes orders for transfer/secretary to call

Doc/facility

PATIENT WAITS

Secretary makes fpllow-up calls

Doc returns call/talks to ED doc

WAITWAIT for return call for bed

availability

Patient discharged

Secretary calls facility for specialty need

Bed available call-backSecretary completes EMTALA paperwork

Secretary copies chart and films

Secretary calls for transport

RN gets EMTALA forms completed

RN calls verbal report Patient Transferred

Hospital transfer ?

Social Work consult written

NO (Nursing Home/Psych facility)

SW talks to family SW calls PCP SW waits for return call

YES

SW does follow-up calls

SW contacts NH & reserves bed

SW copies chart

PCP calls/SW connects doc to RN

SW sends fax notice to Nursing Home

SW calls to verify fax coming

RN calls backSW arranges

transportPatient transferred

PAtiENT WAITING

PATIENT WAITING

Orders given to Secretary Secretary calls consults Waits

Secretary makes bed request in computer

Secretary pages bed placement staff

Secretary erases dispo on white board & writes admit

Consults call back and talk to ED doc

Bed request prints in Admitting

Admitting changes patient status to Inpatient

Admitting RN fills out Admission form (not

always...patient does not wait in ED for this to

happen

Ed RN fills out Report Sheet (ICU is verbal)

ED RN obtains valuables/clothing list

ED RN fills any additional Admit orders

Is patient in “HOLD” status?

RN begins inpatient orders/care processes

RN faxes or calls report to floorNO

YES

RN follows up with floor to ensure info has

arrived

WAIT

WAIT

Patient transferred to unit

Patient transferred to unit

ED RN takes ICU/unstable telemetry patients to

floor...Techs transport stable Telemetry to floor

RN calls transport for Med/Surg patient

Notice of bed availability recieved

ED Process Redesign

Patient ArrivesLPN/EMT Greeter

greets patient

Registrar creates acct, prints labels,

armbands

LPN takes chief complaint

Vol takes patient and chart to intake

room

Vol puts chart in rack outside door

Vol “flicks a flag”(Black flag)

To ED bed?

Intake RN & Doc assess pt in intake

room(10 min process)

To ED bed?

Doc writes orders & determines if pt to go to sub unit or

ED bed

RN/Doc flicks flag-white/green/red

Rn/Doc puts chart in rack ouitside

room

Registrar enters room to complete

registration

Tech/RN takes PT/chart to SAC

Room

Blood draw/EEG/P.O.C. testing/meds

(no IV) done(SAC room)

Orders entered (in SAC room)

Tech/Rn takes PT to results waiting/

ED bed

Chart to Intake rack

PT waits

SAC Team monitors results

Doc reviews results

SAC RM Tech/RN gives results to

doc

SAC RN/Tech transfers PT to procedure room

Doc writes discharge orders

PT waits Volunteer escorts PT out

RN does discharge education

LPN/EMT alerts Charge RN of PT

needing bed

Charge RN assigns PT to ED

bed

Charge RN puts name on tracking

board

Charge RN pages RN to get patient

YESRN brings PT back

to bed

Doc available ?

RN does assessment

RN initiates protocol

Doc/RN do assessment

NO

YES

Doc verifies or writes orders

PT undresses & settles

YES

To ED bed?

YES

Doc takes chart to Unit Coordinator

Unit Coordinator enters orders

Unit Coordinator takes chart to

room and flicks the flag

PT Waits

RN/LPN/Tech fill orders

PT waits for results necessary

for dispo

Results back/Doc reviews

Doc writes dispo Admit

Transfer

Discharge Home

ED Doc gives chart to RN. Chart

flagged

ED Doc to room to discuss discharge

info with PT

Discharge and time on board by

CRN. Chart to POD RN by CRN

POD RN to discharge in 15

Min

If PT needs ride, to waiting area

HomeBed open 15 min

Waiting room for stable PTS (except disoriented or very

infirm)(use volunteers)

Patient waiting

PT moved to transition area

Bed Placement paged

Call back 5 MIN to collect PT info

Bed Placement calls ED in 10 MIN

with floor assignment

Med/Surg/Tele RN to put time & floor

assignment on board

Chart to POD RN. Fax report/verify

fax(FOR ICU: Bed & RN assignment)

PT sent to floor in 15 MIN

POD RN to give verbal report

Patient waits

PT to transition area

Unit Clerk calls facility & accepting

DOC

Accepting Doc calls & talks to ED

Doc

Wait for bed assignment from accepting facility

Unit clerk copies chart, films, forms

& calls for transport

RN does EMTALA forms & calls

reportPT transferred

Patient waits

Disposition Alternatives

Current

Redesign

Color KeyProcess

WaitRoute

ReviewDecision

Locations

Redesign 1 Screening 3 Intake 2 Lab Draw 20 TREAD

Treat and Discharge 20 Acute Beds

Current 3 Triage 5 Fast Track 30 Beds 12 Overflow beds

Scenario Model LOS OutcomesLOS Hours Scenario LOS Current LOS

Minimum 0.65 1.21

Average 3.23 3.98

75%ile 4.04 4.84

90%ile 5.62 6.14

Maximum 17.79 14.24

Clients – Real Outcomes

Goals AchievedPre - Implementation

Jan – Jul 2005

Post - Implementation

First 2 Weeks

Length Of Stay 5 Hours 18 Minutes 3 Hours 3 Minutes

Left Without Being Seen 6.0 % 0.45 %

Goals MaintainedBefore Change

May 2005

After Change

May 2006

Daily Visits 83.0 115.1

Length Of Stay 5 Hours 27 Minutes 3 Hours 9 Minutes

Left Without Being Seen 15.2 % 0.8 %

Clients - Experience Kahn with Insight Strategies - Emergency Process Redesign (6)

CHW-East Valley Chandler Regional Medical Center, AZ CHW-East Valley Mercy Gilbert Medical Center, AZ University Health Center, UT Banner Health Baywood Medical Center, AZ Sun Health Webb Memorial Hospital, AZ Sun Health Boswell Memorial Hospital, AZ

Kahn - Emergency Facility Planning (2) Hospital Israelita Albert Einstein, Sao Paulo, Brasil Foote Hospital, Jackson, MI

SJHS Process Improvement (5) St. John Hospital and Medical Center

Cancer Center, Birthing Center, Registration, Surgery

Detroit Riverview Hospital Birthing Center