Use Super Track
with CNO Janice McKinley and ED Director Darrell Brackett, Parkwest Medical Center, Knoxville, TN
With new minute clinics popping up all over, Parkwest Medical Center (with 45,000 ED visits annually) in Knoxville, TN saw a general rise in the acuity of its ED patients as lower acuity patients were siphoned off. Newly motivated to address length of stay issues with that market segment, the ED resolved to serve them faster. The result? A 50 percent reduction in Left Without Being Seen patients for an additional $230,000 in annualized revenue over the three month pilot in Q4 2009. (A sidenote: Since 1996 when the Parkwest ED won the "Toilet Bowl" award for being in the 5th percentile for patient satisfaction, it's raised it to all the way to the 82nd percentile.)
Getting Started with Super Track
First, ED leaders attended a weeklong training session on lean management techniques sponsored by the University of Tennessee last summer. Then they applied the tools they learned to the length of stay challenge. The goal: Drop door to doc time by 15 percent and reduce length of stay in the Super Track to 50 minutes or less.
The process: A staff team used a lean design method to design a new "Super Track" process to see level 4 and 5 minor acuity patients. To qualify for Super Track, patients must meet specific criteria. Those who do not need labwork, have minor injuries or simple x-rays for ankle injuries, for example, are included. Super Track patients skip triage and are instead greeted by a CNA or nurse practitioner for a quick assessment and immediate bedding. Patients then go through a parallel assessment with a physician and nurse. Afterwards they are discharged or go to x-ray.
Keys to Hardwiring the Process
Meet and measure. In the beginning, a team of high-performing nurses and technicians met weekly to identify which processes were value-added and which were not, to make a dramatic impact in a quick amount of time. Based on their trials and refinements, an industrial engineer would measure and re-measure so the team could visually see the time impact of various approaches. Using immediate bedding to skip wasted time in triage was one innovation that came out of the team's measurement activities.
Identify and Overcome Barriers
The team also identified barriers to hardwiring the process and solutions to overcome them. When it became clear, for example, that the night shift wasn't receiving the same communication as the day shift, they hardwired night shift training by sending a day staff person to keep them current. Also, in the beginning, the staff noticed tremendous variation based on which staff were working. By engaging high performers to train others, everyone excelled.
Track performance. The ED team also uses a monthly dashboard to track daily performance to goal on LWOBS patients, average length of stay, and total ED patients. Updated weekly and posted monthly, the dashboard kept staff tracking to target. This transparency also helped staff understand the effect of mid-course corrections to the Super Track process. "Reviewing results at a daily staff huddle really helped hardwire results and make early course corrections," explains Parkwest's Studer Group Coach Stephanie Baker, RN.
"Now that we've learned how to work through a complex process using lean tools, we're going to tackle other flow issues like diagnosis to discharge," explains ED Director Darrell Brackett. "The Super Track model will be used as best practice for the rest
of the hospital."
The Results
Even though Super Track was implemented during the ED's H1N1 census peak, patient satisfaction remained high and stable because of the newly gained operational efficiency. By December 2009, ALOS was well below the 50 minute goal at 39 minutes—beating the 50 minute goal 30 out of 31 days—and LWOBS had dropped from 3% to 1.6%. What do patients think? Parkwest consistently hears that patients love it through comments on its website and through post-visit phone calls.
A Final Tip
"Set clear expectations and follow through by continually reviewing data," suggests CNO Janice McKinley. "Also, expect some false starts, but keep going!"
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