Operations Management

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The problem of emergency department overcrowding has become an important issue for many emergency departments throughout the city and county of Los Angeles. Patients frequently have to wait hours just to get into the emergency department to be seen by a physician or other healthcare professionals. The problem does not seem to be getting better as times goes on, but indeed studies seem to indicate that the condition is growing worse. At a local Los Angeles County Hospital (King Drew Medical Center) emergency department, we found that the problem is especially severe. Patients are forced to wait as long as 8-12 hours to be seen and treated by physicians. This paper will propose a plan that will help to alleviate this critical problem of emergency department overcrowding and long patients waits for services.

Problem Statement

There is a nationwide shortage of emergency room space and an increased demand for emergency services. Public health officials, hospital executives, and doctors are increasingly concerned about emergency department ”boarding,” because of the potential impact on both patient safety and staff burnout (Kowalczyk, 2005). Our paper will attempt to solve the problem of emergency department overcrowding and long waiting times. We propose to first create a flow chart of present operations from the beginning of the emergency department visit to the discharge or admission of the patient. We believe that the process can be analyzed and changed in a way that improvement can be accomplished by improving efficiency and flow of traffic through the emergency department processes.

Null Hypothesis

Our study attempts to identify a serious problem at a local Los Angeles County Hospital that appears to have plausible solutions. Looking at other similar hospitals throughout the nation and abroad, it appears that restructuring and appropriate panning may help to alleviate long patients’ waits for services. The null hypothesis states that changes in the processes of triage, registration, evaluation, treatment and disposition will shorten waiting times and improve efficiency (mu= changes in process). The alternative hypothesis states that changing in the process of triage, registration, evaluation, treatment and disposition will not change or improve waiting times for patients (mu not = changes in process).

Flow Diagram

Our team will review a current flow diagram that will assist in viewing the present processes that exist at King Drew Medical Center Emergency Room. This flow diagram will delineate the process of the emergency patient presenting to the department of emergency medicine for treatment and evaluation. It will outline the various steps involved in the reception of the prospective patient as he (she) presents to the emergency room for treatment until ultimate discharge or admission to the hospital.

The process will be shown graphically in the form of a flow diagram in order to show the present process and our proposed process of correction that we feel will improve operations. We will attempt to include some necessary detail in the flow diagram, but will be more through in our written explanations and recommendations. Our goal is to cut the total waiting time from the present 10-12 hours to 4-6 hours. We expect to accomplish this 50% reduction in waiting time by improving efficiency of operation and adding new staff if necessary in order to accomplish our goals.

The final flow diagram will reveal a plan to better organize the registration process, the triage process and other processes that a patient may undergo during his matriculation through the emergency department. We will submit contingency plans that can be used when patients do not fit in to a specific category of acuity or when the condition of a patient deteriorates suddenly. The diagram will also offer plans for patients who arrive by paramedic traffic and not by private vehicle. We do not plan to offer budgetary considerations but will attempt to make recommendations that will have minimal impact on budgetary considerations by the organization.

Methodology

The processes involved in the initial encounter, triage, admission to the emergency department, and the disposition of patients seen in the emergency department is a very complex and sometimes convoluted process. This is a descriptive study designed to learn the why, how and when the recommendations will be implemented to improve the admissions and discharge process. There are numerous steps that patients must go through in order to complete the process. Each step has possible roadblocks that could potentially slow the progression of a patient from beginning to endpoint.

This paper will examine each step in the process and will identify the potential roadblocks that hamper the process and offer solutions to alleviate the roadblocks. We contend that the procedures that we will recommend will bring greater efficiency and organization to the entire process for patients who visit the emergency room in this public hospital. Flow diagrams will be included to assist in the understanding and analysis of the processes involved in the admissions process. Inasmuch as personnel is intimately involved in the complex process, we will show how efficient deployment of personnel will improve the process. There may be times when additional personnel will be needed during peak hours of operation.

Data Collection

There will be several data collection tools utilized. Admission and discharge data will be taken from computerized printouts from the Affinity data Collection System with private patient data redacted in alliance with the HIPAA (Health Information Portability and Privacy Act of America) provisions (www.affinitydata.com). Additional data will be retrieved from the Los Angeles County Public Website and from department records that do not contain private protected information. Flow diagrams will be created based upon present policy and procedures. These flow diagrams will be used as a template to develop our system to improve the entire admissions and discharge process. The original processes will be illustrated on the flow diagrams that will allow us to display revised diagrams that will attempt to improve the processes involving triage, registration, evaluation, treatment, and disposition.

A fishbone diagram will be used to demonstrate each area of impediment to efficient movement of patients. The diagram will describe the following processes: a. Laboratory data b. X-ray studies, c. consultation services, d. clerical services, e. urgent care services, e. triage services, f. admission services and processes, g. ICU admission services, h. in-house transportation services and other related services that may impact the triage treatment and admissions process.

Registration Process

Patients must be seen by medical personnel prior to the registration process as required by the EMTALA Federal Laws. This law represent the emergency transport and labor act. This law was put in place primarily to protect women who are in active labor but has been expanded to protect all patients from being transferred to another hospital without a good-faith screening examination. In layman’s terms a person must be seen by a nurse or doctor before they can be asked about insurance or payment capability. There must be an establishment of the fact that no emergency condition exists prior to registration. Once a determination has been made that no emergency condition exists, a patient may now be officially registered.

This process begins by the patient being referred to the registration clerk who requests demographic information as well as insurance and payment information. Hospitals have a right to collect for services rendered and to provide for payment by the patient in the event that insurance coverage is not valid or does not provide adequate payment for services rendered. At a public hospital contrary to popular belief, services are not free. If patients have any means including a home or car or any liquidatable assets they can be attached to pay for services rendered.

Triage Process

The triage process is a very crucial part of the patient’s experience in a hospital emergency room visit (Kelton &Sadowski, 2002). The patient is seen by the triage nurse who evaluates the patient’s complaint to determine if he fits into the category of emergency, urgent or non-urgent. If emergent, the patient is immediately brought in to the main emergency department for evaluation and treatment by a physician. Patients who do not fit into the category of emergent are declared urgent or non-urgent. If declared urgent they are sent to the urgent care center if space is available. If there is no space available, they are sent to the waiting room until space is available. Patients who are declared non-urgent are sent to the triage physician who briefly examines, treats, and releases patient to go home (See Appendix __).

Patients with Emergency Conditions

Patients who fit into emergency categories based upon an emergency lists kept by nurses are immediately brought into the emergency department for evaluation and treatment by a physician. The present process does not have a protocol to assist the triage nurse and this could cause delays in the process. After the patients enters the emergency department appropriate monitors are connected, early intervention occurs and appropriate laboratory and x-ray data are obtained to assist the physician in making medical decisions (See Appendix__).

The Consultation Process

The consultation process is another critical step in the treatment of an emergency patient. This process involves a call to the consultant physician who presents himself (herself) to the emergency department in a timely manner to see an emergency patient. The present process is usually delayed. Our proposal will offer plans to shorten this process. Some consultants are off-campus and hence cannot get to the emergency department in a timely manner. Our plan will change this process and get consultants to the scene in a timely manner.

X-ray Studies

Getting timely x-rays and scans has been a perennial problem for the emergency department and we will offer the solution to this problem as well. There are no designated employees to transport patients to and from the emergency room. Our team will propose a process that will alleviate this problem and decrease the time of this process. There are frequently no radiologists on campus to read scans and x-rays once they have been done by the technicians.

Laboratory Studies

Laboratory data is essential to evaluate emergency patients. Laboratory data is frequently delayed thereby causing a longer time before the physician can make a pivotal decision. We will recommend processes that will enhance and improve the turnaround time for laboratory data. There are frequently no employees designated to transport laboratory samples from the emergency department to the laboratory. This slows the process and delays the return of laboratory results to the physician (See Appendix__).

The Admissions Process

This is a complicated process that occurs after the physician has completed the initial emergency department work-up and the patient has been seen and accepted for admission by the consultant physician. This process involves the admission office where there exists a tremendous amount of inefficiency, which our team will offer a plan to correct this process. A resident physician must call the admission office and argue with a clerk in order to be given an inpatient bed. If the clerk does not feel that this admission is appropriate she will deny the bed and it becomes almost impossible for the physician to gain the admission. This is a flawed process and we will offer the fix for this problem. Once a patient has been given a bed, the patient is prepared for admission and the ER nurse notifies the receiving nurse and the patient is taken to the empty. This process is usually delayed because the receiving nurse has no incentive to receive a new patient and therefore stalls as long as possible. This process delays the admission even further. We will offer a process that will eliminate this roadblock.

Intensive Care Units

At public hospitals there is a distinct shortage of intensive care beds. This is primarily due to the tremendous expense associated with intensive beds. In the private hospital, patients are able to pay for the expensive services offered in the intensive care and intermediary care units. Inasmuch as public hospitals must accept patients whether they can pay for these services or not, the ICU units are always full and hence many intensive care unit patients must remain in the emergency department. Hence, the admission process is delayed. Our team will offer a solution to this problem that will be cost effective and plausible for the public hospital.

Urgent Care Center

Patients who do not have an emergency condition may be sent to the urgent care center. This center treats patients with problems that can be managed without emergency tests and x-rays. There are delays under the present setup due to the registration process and the method by which patients are seen and evaluated in the urgent care center. Our team will offer solutions to this problem and streamline the entire triage process. Urgent care patients should not have to wait long periods of time in order to have relatively minor problems cared for by a physician or other healthcare professional.

Proposals to Improve the Waiting Time for Emergency Department Patients

Our evaluation of the various processes involved in the patient care revealed that there are delays in every aspect of the evaluation and treatment processes. There are delays in the triage, registration, entry into the emergency department, admission, and disposition of patients. Decreasing the elapsed time in each process will decrease the overall experience of patients and create a more efficient and cost-effective process.

Registration

Patients who are registered prior to entry into the main emergency department presently take 30 minutes after waiting in the waiting room approximately 180 minutes. (See appendix__). Our proposal will streamline this process by creating an extra registration window during peak hours. This will increase the speed of registration by 33% (increase of 33% of clerical staff). The increase in cost for the extra registration clerk will be offset by increasing the number of patients seen per hour, hence increasing revenue. Clerical staff will be given public relations training and customer service training which should improve their ability to move patients without friction, which can waste valuable time. We anticipate that each clerk can increase their efficiency by 20-30% based upon comparisons with the private sector.

Triage Process

The triage process appears to be excessive prolonged. Our assessment revealed that it takes approximately 80 minutes. This 10-minute process is much too long and our plan will shorten this time by 50%. An additional registered nurse will be added to each shift based upon workload. One nurse will be used to exclusively perform triage and allow the second nurse to perform patient intake. Each nurse will be cross-trained in order to assist each other when patient traffic increases. A triage protocol will be created in order to assist nurses in making more accurate and timely decisions concerning disposition of patients. Each nurse will be trained to recognize patients who fit into one of five levels. Level-one patients are those with extremely critical problems and level two are those who have less life and limb threatening emergencies. Emergency physicians will be assigned to assist nurses in the triage area when needed. Patients with lower level problems will be routed to theUrgent Care center of the emergency department for evaluation and treatment.

Main Emergency Medicine Department

The main ER is the most complex portion of the process. Changes to this department must be a multidisciplinary process, where many divisions and departments are involved. In order to improve the inner workings of this area, each facet of the department must be analyzed and improved. This includes, the evaluation and treatment by the physician, the consultation process, the laboratory and x-ray services as well as the disposition procedures.

Laboratory Services

One of the most important and crucial part of any emergency departments is the laboratory. Most patients entering the emergency department will require some laboratory data. We propose to improve the laboratory services by providing for more efficient transport. Presently, the ER provides its own transport personnel, which is many times spotty as these transporters have many other ER duties. The process of receiving stat laboratory data takes approximately 2-4 hours. We propose adding new transporters hired by the laboratory to transport blood samples to the laboratory from the ER. This would free up the ER support personnel to perform ER services and allow for faster transport times. We also propose adding additional laboratory personnel during peak hours of services, mainly during the evening shift (3 pm-11 pm). This process should decrease laboratory-processing time to 50% of present time.

Consultation Services

Consultation services are the most time consuming process with in the ER and represent the most inconsistent process within the ER. Some consultants respond quickly but have prolonged decision-making procedures. Other consultants respond very slowly or not at all and make decisions to admit or discharge very quickly. Still other consultants may stall by requesting numerous unnecessary tests in order to save patients for oncoming consultant doctors. This delays the admissions process and is an example of roadblocks that need to be removed. Our group recommends that the ER physician makes the decision to admit or discharge the patient and the consult simply accepts the patient on his (her) service. There could be exceptions but they should be very few in number. Patients who were being discharged could get an early follow-up with the consultant or the consultant could simply come down to briefly see the patient before discharge.

The Admission Process

The admission process is the final process for nearly one-half of the patients seen at a local county hospital. This process is complex and time consuming. Presently, it take approximately 2-4 hours to get a patient to an inpatient bed after the decision is made by the consultant to admit. The process is prolonged due to several steps including procuring a bed from the admission control office. Secondly, getting the patient transported to the assigned bed and receiving approval from the receiving nurse to bring patient to the receiving inpatient service can be a time consuming process which may take 1-2 hours. The availability of transporters may also stall the process or require registered nurses to transport the patient. This process removes a nurse from the ER where she (he) is badly needed. We propose that official transporters be employed for transportation of stable patients and that transport nurse is available for patients who need a higher level of care during transport.

Discharge from the Emergency Department

The final process is the discharge process. The discharge process is a critical bottleneck for efficient patient flow. Slow or unpredictable discharge translates into a reduction in effective bed capacity and admission process delays (Campbell, 2003). Patients who are not being admitted to the hospital are either discharged or transferred to another hospital. Due to insurance reasons, some patients must be admitted to a specific hospital and therefore must be transferred if stable.

Others are discharged home at the end of the treatment process. It is believed based upon observations that patients who are discharged may spend 6-8 hours in the ER. Our proposal will attempt to shorten that total time to 2-4 hours. This can be accomplished by providing for more nurses and physicians during the peak hours of the day, which is usually the evening shift. This recommendation will be costly but may be offset by increased efficiency and the processing of more patients through the ER. Moreover, the proposed triaged process should route more patients to the urgent care area where the waiting times are shorter.

Conclusions

The Emergency Process is a critical process for any hospital. Short wait times and a positive experience represent important drivers of patient satisfaction, while inefficient processes that cannot handle peak demand can result in lost revenues and poor community image, not to mention concern over patient safety. The Emergency Process also represents an excellent place to launch a major change initiative. It has clear boundaries while involving a number of departments, and provides a good first experience at developing the cross-functional change management framework and techniques necessary to drive change through the hospital enterprise more broadly (Wilson, 2004). Patients who leave the emergency department without being seen represent both lost revenue and a failure to successfully fulfill the hospital mission-with potential safety implications.

In addition, poor patient satisfaction due to long wait times and overcrowding will almost certainly cause lost future revenues as some patients choose to go elsewhere. We believe that the processes involving triaging, registration evaluation, treatment, admission and discharge of patients is an important part of the emergency department and is very much delayed using the present processes. Our proposal will attempt to correct each aspect of the entire process thereby creating a more efficient flow of patients through the emergency department. With our proposal the overall time patient spend in the ER was higher than the national average as recommended by the Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org). This process would also have a positive fiscal impact inasmuch as money will be made and expenses reduced by a more efficient process.

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