To determine if team reconfiguration using LEAN/Six Sigma principles can improve the median time of discharge order entry and median time of patient discharge.
At baseline, our service has median time of order entry of 2:05 PM and median discharge of 3:58 PM.
The desired result of reconfiguration, would permit resequencing of the discharge process and advance the baseline discharge metrics during the intervention period.
We were able to significantly reduce the median ED boarding time by 30% from 180 minutes to to 127 minutes, and percent in the ED longer than 4 hours 45% from 39% of patients to 24%.
More information on results at: http://news.psu.edu/story/349580/2015/03/23/research/lean-business-approach-helps-hospitals-run-more-efficiently.
Methods: The study was conducted at a tertiary care children’s hospital to study the sustained impact LEAN changes made to an inpatient pediatric service line had on ED efficiency. Discharge times from the general pediatrics’ service were compared to patients discharged from all other pediatric subspecialty 15 services. We previously reported how we applied Lean Six Sigma (LSS) concepts at an academic children’s hospital to advance patient discharge times. LSS is a process-focused quality methodology that places strong emphasis on creating flow by removing waste and reducing variation by creating standard work. Lean identifies 8 types of waste. They are: defects and rework, over-production, waiting, non-utilization of resources, transport, inventory, motion, and extra processing. In hospitals, patients frequently wait to be discharged from the hospital, and in EDs, admitted patients wait for a bed to become available. Interventions that effectively reduce waiting represent high impact areas and leverage points for healthcare organizations. Therefore we decided to test lean concepts on their ability to help enhance process efficiency and patient flow across the organization. First, our intervention consisted of three changes to the general inpatient pediatrics service:
1) To balance the daily work load, we fundamentally altered the staffing model of the rounding teams to change the patient:attending ratio from 15:1 to 8:1.
2) Defining rounding standards so that teams would round on all patients to be discharged at the start of morning rounds, and do all necessary discharge work and patient instructions at the bedside when the decision to discharge a patient is made.
3) Establishing a daily multidisciplinary pre-discharge planning process. Team staffing reconfiguration permitted all discharge work to be done at the patient’s bedside in “one-piece flow”.
Retrospectively, we determined the impact this had on median times of discharge order entry, patient discharge, and percent of patients discharged before noon. As a marker of ED throughput, we determined median hour of day that admitted patients left the ED to move to their hospital bed. As marker of ED congestion we determined median boarding times.
Results: For the general pediatrics service line, the median discharge order entry time decreased from 1:43pm to 11:28am (p < 0.0001) and the median time of discharge decreased from 3:25pm to 2:25pm (p < 0.0001). The percent of patients discharged before noon increased from 14.0% to 26.0% (p < 0.0001). The discharge metrics remained unchanged for the pediatric subspecialty services group. Median ED boarding time decreased by 49 minutes (p < 0.0001). As a result, the median time of day admitted patients were discharged from the ED was advanced from 5 PM to 4 PM.
The strengths of this study include that it demonstrated sustainability, and that our service line’s performance was controlled against multiple service lines during the same time periods. We demonstrated that team reconfiguration on a general pediatric service in a teaching hospital generates both patient and organizationally-centered results. It reduces patients’ time spent waiting for a discharge in the hospital to occur and patients’ time spent in the ED waiting for a bed to become available Additionally, our project showed that the percent of patients discharged before noon increased and was sustained. This sustained outcome enhanced ED throughput and reduced ED congestion. To address the concerns of those who criticize the discharge before noon objective. We analyzed our average length of stay (ALOS) during the same periods. By framing our work flow to meet organizational goals, our service did not “game the system” to meet the “discharge by noon” metric by delaying patient discharges for the following day, as this would have resulted in an increased ALOS of hospitalized patients and exacerbated ED boarding times. Our ALOS during the intervention was 3.4 days versus 3.8 days during the pre-intervention period. Finally, by creating standard work expectations for the team and implementing an interdisciplinary team huddle, this model appears to be provider independent and one that consistently creates bed vacancies earlier in the day for any pediatric service requesting admission to the children’s hospital.
Conclusion: We believe this study is proof of concept that organizations can relieve critical “access-blocks” to acute care beds by studying new staffing models and employing afternoon inter-disciplinary rounds that plan for next day discharges. Investment in these elements emphasizes bed usage efficiency versus investing in adding additional beds. All hospitalists, either community-based or academic, are in the unique position to conduct center-specific research to begin to address this long-standing quality and safety issue. Future research should determine if this model is generalizable to other types of medical or surgical service lines in either teaching or non-teaching settings. Future research should also assess how earlier patient discharges impact the following: patients leaving the ED without being seen, adverse events, patient satisfaction, provider work-life balance, burnout, and engagement scores, impact on lost referrals and readmission rates. Since our study did include a significant investment in physician labor to staff night shifts, analysis should determine its cost-effectiveness and return on investment by measuring the positive financial impacts that improved bed flow can have on an organization’s value stream, and quality/safety metrics.
In conclusion, we believe organizations must become more value-generating. Improvement in quality, specifically efficiency, will require us to engage our colleagues in the ED and elsewhere throughout the hospital if we want to better understand ways to improve the functionality of our organization. Implemented changes should be process-focused, meaningful, measurable, and value-generating, all of which are the pillars of Lean/Six Sigma methods.
- Michael Beck, Leader
- Kirk Gosik, Member