Dr. Welch was the quality improvement director in the emergency department at LDS Hospital in Salt Lake City for 10 years. She is on the faculty at the Institute for Healthcare Improvement in Boston and speaks internationally on emergency department quality improvement. She also has served as a quality consultant for VHA, is a member of ACEP's quality improvement and patient safety section, and is a member of the Emergency Department Benchmarking Alliance. She has been published in numerous journals, and just finished her second book, “Quality Matters: Creative Solutions for the Efficient ED” to be published by Joint Commission Resources Publishing.
An emergency department director is looking to improve the intake process to decrease door-to-provider time. Staff education does little to improve efficiency, and a colleague suggests using flow mapping, which shows the team the steps in the process and allows them to identify opportunities for improvement.
This flow diagram allowed the director and his team to see the 11 steps between the patient's arrival and his encounter with a physician. This type of intake processing adds delays, and consists of few steps of intrinsic value to patients, but this model is still common in the United States. The director assembled a task force to streamline the process, which began by cutting the number of times the patient went to the waiting room. Eventually the team was so energized to improve this process that they made the most ambitious of all plans. They decided to do away with all intake steps altogether.
This method is sometimes called “pull to full.” If a room is open, the patient is brought straight back, and is met by a physician with all processes occurring in parallel. Sometimes this is called “no triage” or “straight back.” Flow mapping can be done very simply or with more detail, and many computer programs are available to create flow maps. White papers also exist to help novices develop this skill.
Another example of how flow mapping can improve efficiency occurred in a large tertiary care and trauma center that was open less than a year. A physician complained to the ED nurse manager that orders were frequently missed; this was a recurrent complaint from the emergency physician group. The nurse manager audited the charts of the physician making the complaint on the day he had cited and found a disturbing trend.
When comparing the physician orders with the nurses' computerized charting of orders administered, there was a 27 percent discrepancy. In an email to the nursing staff, the manager noted that the physician had seen 18 patients, 15 of whom had orders, and four of those whose nursing orders were either not done or done incorrectly. She also noted that many other orders were delayed. “That is absolutely unacceptable,” she wrote. “You must read and note all of your orders. Remember that if you did not chart it, you did not do it.”
What Data Tell Us
Because the sample was so small, the data seem really out of line. To be sure there really is an issue, she could do small audits over time to get a sense of the magnitude of the problem. On the other hand, this has been a frequent complaint from the physician group, and many would consider even one missed order a sentinel event.
If she assumes the audit is indicative of a problem, is it bad nurses or bad process? Any process that fails 27 percent of the time needs studying. Likely, you will find that this process is not well articulated in the staff's mind and therefore likely to result in defects.
The flow map diagram (see figure) follows the chart of a new patient from generation to nursing orders. Note how the chart moves through a series of destinations and its arrival at each destination cues the team member at each process. The nurses need only to be vigilant and watch for orders. Could this process be changed to make it easier for the nurses to be cued? Could we improve on the reliability of this process by building in redundancy?
Ideas for Change
What would happen if the nurses were presented with the chart as a cue in the same way as the other team members? With little expense or remodeling, chart boxes could be placed on the wall near the nurses' workspace and nametags affixed for each nurse. As the nurse walks to and from the charting area, the chart in her box is presented to her and serves as a visual cue. She is able to pick up the chart and see the new orders right then instead of having other types of cueing (e.g., an electronic tracking system), which require the nurse to retrieve the chart to execute the orders.
The patient flow coordinator also might watch for new orders, and radio a nurse taking care of a complex patient elsewhere in the ED that she has new orders. This is easily built-in redundancy. This also allows other nurses to offer help to a nurse with a number of orders to process. Boxes full of charts with orders can cue the staff about demand capacity mismatch. The charge nurse or patient flow coordinator gets a visual overview of the nurses' workload, and may use this to determine whether the on-call nurse should be called in.
Let's think about adding one other inexpensive low-tech cue. Although we may be moving to computerized charting, some sort of paper chart still exists in most EDs for real-time communication. Highlighter necklaces are inexpensive and an easy way for all staff (nurses, respiratory therapists, EKG techs, and lab techs) to communicate that an order has been executed. It is a highly visual way to communicate. In addition, the entire ED team can be trained to pick up on orders that are not highlighted and to get them processed — more redundancy.
Flow mapping is another tool to improve the processes in our departments. Whether your ED employs primitive skills to visualize the process or becomes a technically skilled and proficient user of flow mapping, the point is this tool allows you to visualize the steps to craft improvements. The final lesson in this piece is that not all solutions to process problems are expensive or high-tech. Get out your colored pencils!