Follow these rules to improve patient flow, quality, and efficiency. We made most of the list in a recent ED meeting, but it applies anywhere patients present.
1. Add value for patients first, always, and without compromise.
2. Never make patients wait unless it adds value for them.
3. Triage means sorting, not primary nursing assessment (see 1 and 2 above).
4. Time is Quality for most care.
5. Nurses and physicians must pull in the same direction at the same speed: ED team = 2-horse chariot.
6. Professionals must do what they do best: RNs do RN work, not clerical work.
7. Remove or unload bottlenecks.
8. Always design parallel processes, not sequential.
9. Design for unlimited capacity; you cannot turn people away.
10. Patients need humanity with every encounter, especially when ‘there’s nothing wrong’.
Do you have any to add? Please share them in the comment section. Thanks!
(image credit: http://blog.cachinko.com/)
This headline comes from Britain (see the link at the bottom).
Many Canadians think they can stop “inappropriate visits” to emergency departments by educating the public. They assume people need more information.
Patients need more access, not more information.
Until we design the system to offer great ways to access care that fits into patients’ lives, we will continue to have patients accessing emergency departments for concerns that could possibly be handled in private offices.
But, we can’t just demand longer office hours. We need to support physicians in the community with acute lab and X-Ray support and attract physicians to work unsociable hours. (We wouldn’t need to attract physicians to work unsociable hours if MDs had to compete for patients.)
Emergency doctors demand seven-day primary care support | GPonline.com.
P.S. If hospitals changed from their current Monday-Friday, 9-4:30 schedules to a 7 day/week approach, we would increase patient flow and patient access, too.
This list should get us started… Please add your ideas in the comment section at the end!
- Close your waiting room – bring patients straight inside to chairs if no beds open
- Use triage to enhance flow: triage = sorting and nothing else
- Limit the number of nurses at triage – 1 nurse can SORT 200 patients per day easily
- Have patients self triage
- Use on-line triage
- Use Bedside registration
- “Quick Reg” – limited registration; just enough to create a chart
- Have patients use self registration
- Offer pre-registration on line
- Post live wait times on-line to smooth patient volumes
- Use patient passports – patient education hand-outs at front door
- Educate the community to arrive in ‘slow’ hours (e.g., before 11am Tues – Fri)
- Educate community to avoid the surges on Sunday evening/all day Monday
- Limit 1 visitor per patient
- Encourage patients to bring med lists with them
- Encourage community MDs to send in referral notes
- Have on-call MDs
- Have flexible start and stop times for MDs
- Get MDs to take responsibility for flow in real time
- Have on call RNs
- Shorten nursing documentation (1-2 pages max)
- Use combined triage & nursing secondary assessment form
- Use physician scribes/navigators
- De-zone – move staff to where need is greatest; don’t leave a zone overstaffed
- Use advanced directives
- Use pre printed orders
- Measure and reward MD performance
- Measure consultant response times
- Insist on in-house consultant coverage for internal medicine, anesthesia, pediatrics…
- De-unionize – flow will improve
- Have nurses only do nursing tasks (carry out orders, give medications), not clerical work
- Track RN break times – insist on accountability
- Reward RN extra effort (staying late, skipping breaks, going the extra mile)
- Match RN staffing to patient volumes by hour
- Match MD staffing to patient volumes by hour
- Never allow MDs to go home if waits are long
- Staff extra MD and RN shifts on known high volume days (Mondays, holidays)
- Encourage MDs/RNs to work in teams and hand over readily
- Stagger RN shift changes
- Have dedicated ED X-Ray
- Have U/S (and tech) in the ED
- Use techs for lab draws and ECGs
- Stat labs
- Prioritize ED lab and DI
- Don’t batch
- Dedicated porters (RN/tech should porter if porters overwhelmed)
- Track DI and lab turn-around times
- Get a great EDIS (ED information system)
- Create meaningful alerts on EDIS to identify LOS, reassessments, etc
- Have a modern EMR linked to the EDIS
- Retire outdated EMRs – an old, slow EMR might be worse than none at all
- Consider a real time locating system (e.g., RFID)
- Consider EMR on tablets for each MD
- Computer terminal in each room
- Link ED EMRs with community EHRs
- Have forms available on-line
- Bypass ED for STEMI identified by EMS (straight to PCI)
- Eliminate phone calls for CT, etc
- Extend CT hours of operation
- Encourage the hospital to work on a 24-7 service model (at least a 7 day service model!)
- Do not schedule big surgical cases on Monday
- Track admits and discharges by time of day and day of week
- Eliminate day-day variations of admits/discharges
- Perform nurse handover on the ward; not by phone from the ED
- Get admitted patients straight up to the ward before a bed becomes available
- Use a visual bed management system for inpatient flow admitted patients leave promptly
- Use patient flow navigators
- Create robust medicine clinic follow-up clinics (next day)
- Do not allow consultants to ‘send patients to the ED’ and see them there
- Teach residents about quality and efficiency as paramount in their education
- Use PO instead of IM, and IM instead of IV treatments if possible
- Position EMS off-load in-front of the main nursing station – not hidden away where patients can languish
- Form psychiatric patients promptly as needed
- Do not perform an internal medicine ‘ward’ work-up in the ED
- Order all tests and treatments on the first touch
- Plan on disposition from the first encounter
- Have Multi-use rooms (eliminate bottle-necks)
- Establish procedures to sedate patients in any room
- Partner with volunteers – they can help a ton!
- Establish CDUs on in-patient wards – do consultations there
- Give every MD, RT and Consultants a phone to carry
- Do not scale down services over holidays when demand always goes up!
- Encourage same day, out-patient cardiac diagnostics and consultation
- Establish direct referrals to cardiology (not internal med, NP, cardiology, etc)
- Have everything needed for work in every area (don’t make staff walk to the ‘tube system’)
- Use pre-printed prescriptions
- Have the chief call in 2-3 times per day to monitor flow
- Create an internal, real-time ED surge plan
- Create a hospital wide surge plan and link it to the ED surge plan
- Give admin on call authority to move admitted patients out the ED
- Have back on-call to support internal medicine consults
- Do not allow surgeons to be on-call to the ED on their OR day
- Teach all nurses to apply splints and/or casts
- Use ‘just in time’ approach to patient movement – don’t stock-pile patients by loading rooms
- Avoid batching
- Assign patients to areas; not rooms
- Use overhead paging liberally – don’t walk around looking for patients
- Improve patient signage
- Use patient instruction sheets
- Use a re-assessment check-list so MDs aren’t called to reassess prematurely
- Build a minor treatment area (aka fast track)
- Get rid of as many stretchers as possible (limits holding admitted patients)
- Use exam tables where-ever possible
- Use some chairs instead of stretchers in the acute area for telemetry patients
- Get rid of walls – use curtains to divide most rooms
- Eliminate sequential processing
- Insist on parallel processing
- Look for bottlenecks – theory of constraints
- Learn queuing theory and how it applies to your department
- Learn and love LEAN
- Employ an unlimited capacity mindset – don’t limit flow for lack of ‘rooms’
- Adopt a ‘get it done NOW‘ attitude across the organization!
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