Improving Turnaround Time Of Emergency Departments In Hospitals: A System Thinking Approach

Background

Emergency Departments or EDs of the hospital are generally considered as the primary resource towards addressing unexpected general as well as critical healthcare problems. But a general issue associated with the operations of an ED is the high wait time or the “Turnaround time” associated with a patient’ arrival to the hospital to the time “medical care and treatment” are received. There exists a number of loopholes or planning issues that might impact the efficiency related to the “timeliness of care delivered” and “the quality of the care and services” being delivered. These issues can generally be observed as resultants of complex and uncertain operational planning issues associated with the systems that ED departments work with. This paper intends to utilize the “System Thinking” approach to address these issues. It will allow the research participants to focus over every participating constituent within the operational plan and flow of an Emergency Department and structure the required holistic approach to address the same.  

The report will critically analyze and provide recommendations to improve the efficiency of the Value Stream Map related to the operational plan of a Hospital’ Emergency Department (hypothetical). The core focus will be on understanding the nature of the “value stream map” and identify the necessary changes required to increase the operational efficiency while accounting for possible intended as well as unintended consequences.

Considering its association majorly with medical issues that required a critical and urgent response, Emergency Departments in healthcare service delivery have always been considered as a vital domain. But evidently, there are a number of issues (Planning as well as operational) that might impact the efficiency of service delivery in Emergency Departments. Before analyzing the current State value stream of the emergency department (given hypothetical case), it is important to identify the key system archetypes that may impact the performance of such a system. Reflecting from the System thinking approach following are some of the system archetypes that are highly likely to impede the performance of ED(s). (Anand & Kodali, 2009)

Shifting the burden

Generally, the organization implements short terms solutions to address a problem or task in hand in order to gain immediate results. (Bal, Ceylan & Taço?lu, 2017) These solutions do provide immediate results but it compromises the quality of the corrective measures that are suitable for long-term efficiency eventually leading to a disturbed environment.

Success to Successful

There are high chances that organization assign multiple assignments and projects (patients in this case) to the professionals who have previously achieved significant success or has significant experience, whereas on the other hand professionals whose performance/experience have been significant. This, in turn, restricts the other professionals from getting suitable chances to grow their skill level and experiences.  

Growth and Underinvestment

This archetype focus on highlighting the situation where junior employees (nurses and doctors as in this case) are not trained with suitable commitment resulting in underdevelopment of their skill set and eventually restrict their growth in the profession. (Finamore & Turris, 2009)

Identification and analysis of the System Archetypes that may impede performance

In addition to these, there are other possible archetypes such as “Tragedy of Commons” (focusing over a standard process or procedure for every case) or balance process delay resulting in an imbalance of recruited manpower that can impact the overall performance of the Emergency Department processing.  (Lee et al., 2015)

Let us now analyze the current state value stream map of the emergency department and evaluate the same on the grounds of above archetypes.

Analysis of the current State Value Stream Map of the emergency department based on System Archetypes

Current State Value Stream Map

Overview of the current process

The state value stream map clearly represents a sequential and simplistic patient handling process. The incoming patients are initially registered (in case the patients are returning their details and history are reused). Following the registration process, the patients are made to spend time in the waiting area (one of the core reason behind the increased waiting time). Thereafter the patients are sent to the ER room where the nurses conduct primary examinations or diagnostics on the patient and prepare a report. Then the senior doctor or physician conducts his/her own diagnostic process and then structure the medical care procedure required. (Lummus, Vokurka & Rodeghiero, 2006) Thereafter the treatment is given and the doctor issue diagnostic and departing instructions to the nurse who then conveys the same to the patient before he can leave for home. The insurance company directly interact with the hospital and take information from the hospital administration related to the patient’ medical history.

Identifying the possible areas or factors impacting the performance levels (Aligning the areas with the archetypes)

No evident Triage structuring: As evident from the above state value stream there is no evidence of “Triage” structuring. All the incoming patients are addressed with a similar action plan and there is no priority base “care and treatment” action plan structured. Ideally, the condition of the patient should be evaluated as soon as he enters the hospital and the care process should begin as per the severity of the condition or illness the patient is going through. This will not only help the hospital management to reduce the wait time of patients who need urgent care but suitable care can be provided to the patient considering the severity of the condition. This issue or lack of planning can be aligned with the “Tragedy of common” archetype where a process/professional/activity that has previously delivered results is considered optimum for every case. In certain case following a standard process for every requirement may result in creating blockades and in turn reduce the efficiency of the process. (Sayah, Rogers, Devarajan, Kingsley-Rocker & Lobon, 2018)

Repetitive efforts: The above process clearly reflect that significant time is wasted when both the Nurses and the Physician asks the similar kind of questions to the patients. The actual focus of the value stream map is on shifting the Burden (archetype) of doctors related to the execution of pre-requisites such as collecting information and detail related to the condition of the patient. The same case is evident when departing Instructions are given to the patients. The instructions are initially given to the nurse who then passes to the patient. Significant time can be saved by creating a direct link between the patient and doctor itself. If the doctor has to evaluate the condition of the patient himself then there is “no need to conduct primary diagnostics” by the nurse and the departing instructions can also be given to the patient directly by the doctor. Both these steps will save time and reduce the turnaround time related to the delivery of care and treatment to the patient.

Analysis of the current State Value Stream Map of the emergency department based on System Archetypes

Revised State Value Stream Map

Implementing Triage Practices

The primary consideration that the hospital needs to consider for improving the turnaround time of patients in the hospitals is to implement “Triage” structure. As soon as the patient enters the hospital and registration process is completed, the Severity study related to the situation of the patient needs to be conducted. Instead of making the patient wait for the availability of ER room, they can be sent to a primary common ER Hall along with other patients where the nurses should conduct primary diagnostic of the patient against a specific set of elements like “possible illness or disease”, “Duration”, “intensity of the issue they are facing”. (Sinreich & Marmor, 2005) Based on this assessment, the severity of the case can be calculated to analyses whether only general consultation is required or patient needs critical care immediately from specialist physicians.

Severity based response

Based on the identified severity of the case the patient who needs critical care and treatment should be prioritized and physicians should be allocated to them immediately. In case, the senior staff is not available at the moment, the junior doctors need to take care of the patients till the time the senior staff is available.

Similarly, if the severity of the case is not high, concerned junior doctors and staffs should be allocated to the patients and the senior staff should be left free for addressing high severity cases and critical condition patients.  

Regularly documenting the patient conditions

The condition of the patient needs to be documented in a structured manner so as every consulting physician or doctor can have a direct reference to the medical condition of the patient without any delay or waiting time. (Wong, Morra, Caesar, Carter & Abrams, 2018)

Other possible ways to improve the turnaround time

• The doctors can themselves provide the discharge instructions to the patients during their visit to the patient. This will save the time which is wasted due to the navigating the instructions from the hands of the nurse.

Remaining processes can be followed in their existing state.

Availability of more resources to reduce wait time: Such an act will ensure that primary care is provided to the patients within 15 mins of their admission into the hospital and further a fewer number of doctors can be used to serve a larger patient base in an effective manner. This will optimize the State value stream process as well as the turnaround time of the patients in the hospitals.

• Improved Turnaround time for patient treatment delivery
• Reduced needs of dedicated rooms
• Optimized use of human resources both experienced and junior professionals.
• The skill set and efforts of Nurses and other support staff will be improved

Such an initiative will not only build the skill set of the junior staff but will allow the hospital to make their existing staff more competent to address the patients individually. Hence in case of increase inflow of the patients in emergency situations, the hospital will be able to address the demand with efficiency. (Wong, Morra, Caesar, Carter & Abrams, 2018)

• Increased competence of the professionals
• Increased opportunities for junior professional to gain skills and experience from their seniors.

Conclusion

The above analysis clearly revealed that the most evident issues associated with the Emergency Department operation are associated with ineffective planning. In order to improve the hospital needs to restructure their process flow. The above-mentioned considerations can significantly help the hospital to improve the associated turnaround time and increase the efficiency of operations. Following are some additional recommendations that can come in handy for the hospital:

• Implementation training programs for junior staff and nurses help them to improve their competence level and handle the primary care practices with high efficiency.
• Growth and Underinvestment is an archetype that can be clearly associated with the current recommendations for improving the efficiency of the Emergency department of the hospital. There is the evident scope of improvement in terms of the efficiency that can be added to the process by offering multiple opportunities for the junior doctors to work with seniors and in turn develop and improve their skill base.(Wong, Morra, Caesar, Carter & Abrams, 2018)
• Further, the hospitals can invest their efforts in structuring the laboratory system in an effective manner so that minimum time is wasted during conducting lab tests of the patients.   

References

Anand, G., & Kodali, R. (2009). Application of value stream mapping and simulation for the design of lean manufacturing systems: a case study. International Journal Of Simulation And Process Modelling, 5(3), 192. doi: 10.1504/ijspm.2009.031094

Bal, A., Ceylan, C., & Taço?lu, C. (2017). Using value stream mapping and discrete event simulation to improve efficiency of emergency departments. International Journal Of Healthcare Management, 10(3), 196-206. doi: 10.1080/20479700.2017.1304323

Finamore, S., & Turris, S. (2009). Shortening the Wait: A Strategy to Reduce Waiting Times in the Emergency Department. Journal Of Emergency Nursing, 35(6), 509-514. doi: 10.1016/j.jen.2009.03.001

Lee, E., Atallah, H., Wright, M., Post, E., Thomas, C., Wu, D., & Haley, L. (2015). Transforming Hospital Emergency Department Workflow and Patient Care. Interfaces, 45(1), 58-82. doi: 10.1287/inte.2014.0788

Lummus, R., Vokurka, R., & Rodeghiero, B. (2006). Improving Quality through Value Stream Mapping: A Case Study of a Physician’s Clinic. Total Quality Management & Business Excellence, 17(8), 1063-1075. doi: 10.1080/14783360600748091

Sayah, A., Rogers, L., Devarajan, K., Kingsley-Rocker, L., & Lobon, L. (2018). Minimizing ED Waiting Times and Improving Patient Flow and Experience of Care. Emergency Medicine International, pp-8. https://dx.doi.org/10.1155/2014/981472

Sinreich, D., & Marmor, Y. (2005). Ways to reduce patient turnaround time and improve service quality in emergency departments. Journal Of Health Organization And Management, 19(2), 88-105. doi: 10.1108/14777260510600022

Wong, H., Morra, D., Caesar, M., Carter, M., & Abrams, H. (2018). Understanding hospital and emergency department congestion: an examination of inpatient admission trends and bed resources. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20078914