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Sycamore Medical Center's Lean project to improve patient flow in the emergency department resulted in an increase in patient satisfaction scores and a decrease in patients who left without being seen. A multidisciplinary team analyzed how patients arrive, how they are treated, and how they are triaged. The team examined the work of all emergency department staff and made changes to optimize their time. The team created a set of essential care orders the hospital can use if the patient is stable and can go to the floor.

To improve door-to-needle times for stroke victims, a multidisciplinary team at Barnes-Jewish Hospital in St. Louis, MO, used lean methodology to identify opportunities for improvement and implement changes aimed at streamlining the care process. As a result, since first implemented in February 2011, average door-to-needle times have improved by nearly 40%, and the number of patients treated within 60 minutes has increased from 52% to 78%. To accelerate care, pre-hospital providers are now empowered to activate the hospital's stroke team from the field. Also, potential stroke victims are brought directly to the hospital's CT scanners rather than the typical entry point in the ED. While patients are at the CT scanner, all the stroke team members assemble to assess the patient and ask critical questions so that all information is shared up front with all the clinicians at the same time. This replaces a process that relied more on serial processing, in which patients would see clinicians more on a one-on-one basis The ED introduced point-of-care testing for PT/INR.The move has enabled clinicians to get test results within 10 minutes rather than 40 minutes. This facilitates quicker decisions on the use of thrombolytic drugs.

The ED at The Aroostook Medical Center (TAMC) in Presque Isle, ME, is a level II trauma center. It is the largest in the region, with only 89 beds. It has undergone a transformation in recent months, with average wait times to see a provider going from four to five hours down to less than five minutes, and the left-without-being-seen (LWBS) rate has been slashed from a high of 7% down to less than 1%. The hospital says the improvements are the result of lean-driven, staff-designed solutions, coupled with administrative engagement and oversight. And administrators say more improvements are on the way in 2013 when a hospital-wide workgroup will try to clear away obstacles and inefficiencies from the hospital admissions process. To tackle long wait times among patients with lower triage levels, the ED instituted a fast-track system, manned by mid-level providers and a tech or LPN. Responsibilities for charge nurses have been redesigned so that they have the power to monitor and facilitate patient flow. The ED has initiated more point-of-care testing so that nurses and techs can conduct many routine tests on their own. While the lean model relies on staff-driven solutions, administrators make the difference when it comes to sustaining changes and minimizing employee resistance.

Measurements will include mortality, appropriate care, efficiency, harm avoidance, patient satisfaction. Improving health of communities is one of program's primary aims. Goal is to move 50% of participants into the top quartiles for all measures.

Initiative demonstrates a 23% improvement in first bed assignment to a private isolation room. Keys to improvement found in enhanced communication and staff training. Staff develop reporting mechanism to sustain and institutionalize project results.

Moving toward improved quality and patient safety requires that the ED manager address three key issues: environment, staffing, and competency. "Rub your hospital's nose in the boarding problem", advises one ED manager. Make sure the competencies of your staff match the needs of the specific populations they serve. Develop a method for determining the most appropriate levels of nursing staff.

System undertakes 150 rapid process improvement workshops. Eliminating various types of waste is one of key foci of lean production approach. Time is main metric of methodology; observers measure processes with stopwatches.

By regularly surveying patients and staff, you can stay on top of key issues that need to be addressed. Daily surveys are easily done with a representative sampling of patient census and key staff members. Addressing staff complaints in a timely manner can contribute to decreased turnover rate. Small changes are easier to accomplish than major ones and often can be just as meaningful.

Six Sigma, an approach to performance improvement that originated in the manufacturing sector, is being applied readily to the ED environment. Turnaround time for ED lab specimens is reduced by 30 minutes. Many ED processes have multiple steps. Six Sigma approach identifies subprocesses for targeted improvement. Data-heavy analysis eliminates the emotional component of problem solving. Bedside nurses and phlebotomists all are equipped with pagers to speed the process of getting blood samples to the lab.

Even if it were not required, quality managers would implement patient grievance policy. Hurt, frightened patients may be more likely to complain. Know the difference between a complaint and a grievance.

Significant revenue opportunities and reduced cost per case are possible. Methodology focuses on creating new measures of effectiveness for key factors. People, process, and tools addressed to drive culture change.

Key elements must address quality, efficiency, and feasibility. Committee piggybacks on ongoing study for faster results. Common industry standard for software developers being created.

Decision-making body or individual a key variable in prioritization. Start with more obvious QI areas to develop a comfort level. Is it harder to motivate staff to study issues that might become problems?

Keeping a score card can identify problem areas and track improvements. When specific goals are reached, staff are given rewards such as thank-you letters, tokens, or pizza parties. Staff are kept informed about the results of the score card through bulletin board postings, staff meetings, and the hospital Intranet. Data are collected with manual entry by nursing staff, chart review by performance improvement, and a computerized program.

Appreciative Inquiry, or Al, seeks to identify what went right and duplicate the experience. Adjustment in thinking may be difficult for defensive-minded health care professionals. Likelihood of success appears greater when smaller groups are involved.

Technology wasn't the starting point, but new system provides ample information for positive change in Indianapolis.

With $2 million in grant money, seven facilities aim to improve patient care, safety, and disease states.