Improving the ER flow at Cox Monett

In the Cox Monett ER, charge nurses Julia Eden and Margaret Kleiboeker check the patient tracking board, which offers an at-a-glance view of work under way in the department. The board was recently expanded to include more details about what tests have been ordered and which are complete. The changes were one part of a lean project aimed at coordinating care in the department. 

The culture of an emergency room is, by definition, fast-paced; when problems present themselves, people move quickly to solve them. That approach is ideal when you’re dealing with acute, immediate issues like injuries and illnesses. But taking on broad challenges, like improving patient flow in a busy ER, requires a different approach.

Since February, staff members in Cox Monett’s Emergency Department have been improving the way they work through a lean project that is focused on throughput and workflow efficiency. For those who have built a career in emergency care, the systematic approach of lean has been a major shift of gears. 

“The pace is very logical and methodical, but you have to do it,” says Beverly Morris, nurse manager in the ER. “It’s tough for fast-paced ER types to slow down and take a step back.” 

Over the past few months, the lean team has helped staff members do just that. They’ve been examining how patients experience care in the ER and looking at ways to streamline their work to reduce wait times. At the same time, staff members have become versed in the methodology of lean, which requires carefully mapping all the steps in a process and looking for waste that can be eliminated. The team has gathered people from a variety of departments to look for ways they can work together to improve care and the patient experience. 

“We’ve spent a lot of time understanding the current situation,” says Genny Maroc, president of Cox Monett. “This is a very data-driven approach to build the business case for the project.” 

The lean project continues this summer, but so far the measured, big-picture approach is paying off for staff members and patients. 

When the project began last winter, it was designed to improve throughput and efficiency in the ER. About 1,200 patients visit the Cox Monett ER each month and that number is up by 5.2 percent over this time last year. As the volumes rise, so does the number of patients who leave without being treated. If the lean team could find efficiencies and reduce that number, it would have a two-fold benefit: improving satisfaction, for both patients and employees, and capturing revenue for the system. 

Early on, Morris says it was clear that the issue of throughput was an “elephant-sized” problem; to address it, it would need to be broken into smaller parts. The lean team began looking at the door-to-door times: how long it took from a patient’s initial arrival at the ER until they were discharged or admitted. 

Maroc says the data indicated that if total door-to-door time could be improved by 20 percent, it would cut out 30 minutes from each visit. That, in turn, would allow the ER to serve 700 more patients per year. 

To begin getting a handle on how to make that improvement, the team further broke down the patient experience. They focused on the first half of that door-to-door process: the time spent between patient arrival and the work done by ancillary services such as laboratory, radiology and respiratory care. That timeframe, called “door-to-ancillary complete,” would be the first target for improvements. 

In a relatively small facility like Cox Monett, many ancillary departments multi-task, managing their own outpatient volumes and duties in the hospital with working in the ER as needed. 

It can be tough to coordinate the ancillary work in the ER, especially if a patient needs assistance from multiple departments. 

“When respiratory care, lab and X-ray all respond at the same time, it can disrupt a smooth patient flow,” Morris says.  

The lean team identified two major solutions, or countermeasures, they could put in place to improve that flow: an enhanced computerized tracking board and adding a patient flow coordinator. 

The ER already had a computerized tracking system, but the team worked with staff members to identify improvements that could make it a more effective tool for coordinating all of the work that takes place in the department. 

Jeff Graham, applications technology manager in IT, worked with the team to add new features that offer more detail about what tests have been ordered and how close they are to completion. 

The ER tracking board now shows four new icons: CT/ultrasounds; urinalysis orders; in-house labs; and labs that have been sent out. In the past, a column for labs on the tracking board might have shown, for example, that eight labs had been ordered and six were back. What it didn’t make clear is that the remaining two were sent out- of-house. Now, the board shows how many labs have been ordered; a hospital icon indicates they are in-house, while a bus icon indicates they have been sent out. 

“The tracking board has been a great success,” Morris says. 

The icon for urinalysis orders provides a quick visual cue for everyone in the department, letting them know which patients require a urine sample. Staff members can then easily check in with waiting patients and collect the sample when patients need to use the restroom.  

In addition to the new levels of detail, ancillary departments can now see tracking board information from their desktops, which helps staff members see when the ER is getting busy and where the ER staff is in its workflow. 

“They can see our volumes and know when to expect orders,” Morris says. “They used to look at individual orders on the computer, but now they can just pull up the whole tracking board.” 

As a second countermeasure to help coordinate care, the department was getting set to try a new position beginning in late June: an ER flow manager. The flow manager (a nursing staff member) will be responsible for knowing the status of all patients in the ER and triaging the workflows; knowing which patient the physician needs to see next and coordinating the work of ancillary departments for maximum efficiency. 

“In the past, you’ve had three nurses telling the doctor information; one nurse doesn’t know what the others have shared,” says Heidi Clark, house supervisor. “This position, with one person aware of everything, may fix that.” 

The flow coordinator will also have access to a new push-to-talk phone system similar to the ones in use in the Cox North and Cox South ERs. The phones will allow the ER to have instant communication with ancillary staff members.  

“When the patient orders go in, the flow manager can push a button and talk to lab and X-ray staff together and instruct lab to come first, followed by X-ray. There is no phone call to interrupt workflows,” Morris says. 

In late June, the department was going to do three test periods with a flow manager to collect data to see how much difference the position makes. 

In addition to the major countermeasures, the lean project has also uncovered some simple fixes that have made work flow more smoothly. One example involves the location of printers that produce the printed orders for lab and radiology. In the evenings, there are fewer techs in those departments and they may be working in the back and miss an order that prints out in the front of the office. The solution? Move a printer into the back of the department, so orders print where staffers are in the evenings. 

Charge nurse Julia Eden says those simple changes that make things smoother for employees can do a lot to improve employee satisfaction. 

“Sometimes, patient frustrations are more easily seen, but it’s frustrating for staff, too, when there are delays and inefficiencies,” she says. “A lot of these changes help us work smarter, not harder.” 

Pat Blamey, director of Radiology, says the lean team meetings were a chance to boil down the steps in the patient experience and better understand the challenges faced by  each department. Just by talking to one another, the group was able to find ways to be more efficient. 

For example, Blamey says ER staff members had developed a workaround to cope with the wait times for radiology films to be read. After a test was completed, the film would be read at Cox South. ER staff get the results by calling a dictation line, but staff members reported that they often had to listen to a couple of unrelated results to get to the one they needed. 

“When I heard that, I asked them, ‘Are you using the shortcuts?’” Blamey says. “It turns out that they had lost those instructions. So we printed new ones!” 

Also, ER staffers didn’t know how quickly their films would be read. They didn’t want to call twice, so they would wait to make sure the results would be ready by the time they called, which caused delays.

“Someone else in the room pointed out that there is a fix for that – an IT solution that would group your orders and let you see when they have been completed,” Blamey says.

Staff members say the opportunity to sit down with co-workers from across a variety of departments to talk about the patient care process and work on solutions together is a big part of the power of a lean project. 

“It’s eye-opening for everyone to see how things affect other departments. As much as areas like lab, ER and radiology work together in the interest of the patient, we tend to work in our own segmented groups; we know our processes but we don’t know 100 percent what their processes are,” Clark says. “Very seldom do we have meetings with all of those entities present at the same table. You get a better understanding of what everyone has to do and it makes it easier to work together as a team for the patient.” 

Having everyone at the table working together has produced a clear understanding of the ER’s needs and it has allowed the team to prioritize the improvements they’re considering. Meanwhile, the lean project has provided a data-driven framework for assessing those needs and tracking the effectiveness of the countermeasures, which justifies the investment some improvements require. 

“Some of these ideas are ones people have had for a while, but lean has allowed the right people to be involved to make these changes,” Clark says. “It’s allowed us to move forward and make those ideas a reality.” 

In the coming months, ER staff will be studying the success of improvements like the tracking board and the flow coordinator. They’ll also be working on smaller changes, such as adding color-coded flags for each patient room, to indicate quickly and visually where a patient is in the process.

As the project heads into its final stages, participants say the fast pace of their daily work is improving as a result of decisions made in the methodical lean process. Their advice for other departments who are about to embark on a lean project? Be ready to change the way you think and be willing to follow where the lean process takes you.

“You have to let the process guide you. With the meetings and the tools you’re given, it’s like the lean team is in a boat, in a river, and it will take you there; you have to not paddle against it,” Morris says. “I’m used to paddling, but you have to float.”

 Going with the flow of a lean project is easier when everyone remembers that the goal is to keep the patient at the center of everything we do.

“You have to be open-minded,” Eden says. “People are afraid of change, but this is about a better work environment and it ultimately will make patients happier.”
About lean 

Lean thought has its roots in a process improvement discipline developed by Toyota. While it began in the world of manufacturing, the lean approach can be used to examine and improve a variety of work processes. Here are a few of the terms you’re likely to hear as lean projects are deployed at CoxHealth:
Muda: A Japanese term for an activity that is wasteful and doesn’t add value.
Gemba walk: When leaders examine first-hand how work is done on the front lines. They’re visiting “gemba,” or “the real place” in Japanese.
Value stream: All the steps in a process of producing or delivering a product or service. Value streams are mapped to show the flow of information and work in the process. How work is carried out at the beginning of a lean project is defined on a current state map while a goal for how processes could be improved is spelled out in a future state map.