Case Study: Urban ED Process Drives Design

A Deeper LookAs Emergency Departments continue to serve a variety of roles in their communities, those in urban areas feel the pressures of both tertiary care and large numbers of underinsured patients with basic medical needs. Understanding the unique factors that each facility faces should drive solutions rather than national benchmarks or averages. Using predictive analytics and simulation modeling, we help each client develop the best solution for their situation.

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EMERGENCY DEPARTMENTS

CHALLENGEAn urban academic medical center

focused on pediatrics sees more than

85,000 visits each year in their emergency

department. Designed 15 years ago, the

segregated pods and small triage area limit

flexibility and result in long lines and unsafe

conditions.

SOLUTIONThrough process mapping and discrete

event simulation, a multi-disciplinary team

was able to test alternate patient flow

approaches to identify the optimal balance

of process time and staffing resources to

ensure consistent success.

Process-Led DesignPRoCESS ovERviEw

Before we consider architectural solutions, we design the process. In this case, Lean improvement work had been underway in the Emergency Department. Rapid testing and data-driven decisions guide our work. When appropriate, we employ simulation modeling and predictive analytics to help clients make important early design decisions with clarity and certainty.

The group had reached a threshold they believed needed to be overcome with an integrat-ed process and space configuration solution. We were able to leverage existing through-put data to rapidly build a simulation model.

Implementation Methods:

• Simulation

• Process Mapping

• Observation

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CuRRENT CoNDiTioNS

Time was of the essence. Check-in lines were long and creating unsafe supervision conditions in the waiting room. Door-to-Doctor times were longer than accept-able for some patients. Length-of-Stay was much longer than national markers. Patients and their families were waiting at every step in the process.

The care of emergent pediatric patients is complex. Rapid decompensation and non-specific symptoms make any unsupervised wait dangerous. In an effort to gain as much information as possible, a two-step triage and assessment process was in place. Protocols could be started early and providers knew that patients were evaluated in detail even if they had a long wait. The unintended consequence was a bottleneck at assessment.

To combat the problem, the providers felt a redesign of the arrival area was neces-sary in conjunction with process changes to combine some existing care steps and reduce patient moves. While this seemed like sound logic, we were concerned the root cause of the problem might be deeper. Together, we conducted an eight-week process-led design study to understand the current condition and develop a sus-tainable future state model.

We were able to reduce wait times to less than five minutes for 99.02% of patients

Allowing every staff member to work to the top of their license improves care.

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DATA

Using data the internal Group already collected, we developed a simulation model to test the implication of process deci-sions on overall throughput and resource needs. We created a dynamic tool that allowed the team to change the variables during our future state design meeting. This real time feed-back allowed quick consensus and decision making about the ideal future state.

It became apparent through simulation that combining triage and assessment would slow down the system further and re-quire a high number of triage nurses to handle peak volumes.

The providers felt it wasn’t the best use of so many high-ly-trained pediatric emergency nurses to be tied up in triage.

The Lean Group appreciated the simulation exercise and how it brought to light that simply com-bining triage with assessment wasn’t their best solution. Fewer patient moves didn’t necessarily improve care. Focusing then on reducing overall length- of-stay (while still attempting to reduce patient moves), the group instead moved assessment to the bedside and reduced the length of the initial contact to a more conventional triage. This allowed them to quickly register and evaluate the large volume of patients they see each day with wait times of less than five minutes for 99.02% for all patients.

FuTuRE STATE

Through process redesign of security, registration and check-in, and the shifting of the nursing assessment to the bedside, patient throughput could improve by focusing on the key infor-mation at each step. Through simulation we determined that adding one additional registrar reduced overall wait times and allowed two nurses to return to bedside care within the current staffing model.

Implementation

# of Patients Waiting

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After robust process design, it was time for architecture to sup-port it. Shifting to a more traditional triage approach left some providers concerned about waiting room oversight. Through continued process-led design, we developed a one-way flow model that moves patients to sorted waiting areas that can be overseen by clinical staff immediately following initial triage. This arrangement also allows the triage nurses to maintain visu-al oversight of the main entry.

No process is perfect. This configuration allows for some key process shifts in real time pending census. Registration lead-ership can support front desk staff through their direct location. Additionally, nursing leadership can implement a pivot nurse pre-sort process if volume spikes unexpectedly. The front desk and triage area was purposely designed to support a flexible staffing model that can evolve over time.

SuMMARiZiNG CoNTiNuouS iMPRovEMENT

Our core mission is the same as that of our clients, improve the quality of our work, increase our efficiency, and motivate our staff to reach for success. At Array, we are establishing a culture of continuous improvement at all levels of our organiza-tion. We seek to empower members of our team to be agents for good change. We have re-designed our design process using Lean as a foundation for a unique Process-Led approach that better meets the needs of today’s healthcare organizations. We believe the transformative improvement that leading health systems, who have embraced Lean and other improvement approaches, have achieved is equally applicable to architecture.

Who We AreARRAY-ARCHITECTS.COM

We Are Healthcare Architects

We are a team of architects and designers with unique backgrounds, but we all have one thing in common - we share a strong desire to use our expertise and knowledge to design solutions that will help people in moments that matter most.

This focus makes us leaders in our field. There’s a degree of compassion, empathy, and sensitivity that goes into every project that we touch. It’s designing a nurse station with sight lines to every patient. It’s building a Behavioral Health facility without corners, so that patients are safe. It’s translating the operational needs through the technical details to fine tune the lighting system in a neonatal unit so caregivers can match the lighting to each baby’s stage of development. It is a deeper understanding, honed through relationships spanning

decades.

Together, we discover optimal solutions with our clients. It is our four decades of specialization that allows for effective communication, collaboration and precision in the complex, changing world of healthcare.

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