Problem Statement Problem Analysis Jan 2012 – Dec 2013

Action Items Actual Benefits Jan 2013 - Dec 2014

Efficient and effective operations within the Emergency Department help assure that patients are seen rapidly appropriately prioritized and

receive the appropriate assessment and disposition in a timely fashion. ED Throughput (time from arrival to departure, Core ED-1a-

Overall LOS) is not meeting performance targets (175 minute average)resulting in decreased patient experience, delays in transition to appropriate care setting and decreased ED capacity. Coordination

of the patient care process from patient arrival to departure from the Emergency Department and streamlining or/removal of barriers to

timely care will have a positive impact on patients, caregivers/family, staff, providers and the organization.

•Implement RIE to improve decision to discharge time for admit patients (Core ED-2a)•Implement RIE to improve decision to discharge time for discharge patients•Place mid-level provider in Triage•Implement RIE to improve Diagnostic window time•Reduce LWBS•Reduce AMA and Eloped patients•Improve department staff morale•Design ED process

ED Throughput Project

Problem Statement Problem Analysis

Action Items Actual Benefits

LMC is currently redrawing an unknown of specimens due to mislabeling. Mislabeled specimens are required

to be redrawn from the patient. Not knowing the actual amount of mislabeled specimens disables the

improvement process from identifying the root causes of mislabeled specimens. It also delays results from the lab, which in turn delays diagnosis time for the patient which leads to longer LOS stay times in both OP and IP

environments.

Heart HospitalTime frame: 8/28-12/02/13

Source: incident reports and photos

LMCTime frame: 9/13-10/23/13

Source: MIDAS

•Paperwork at Lab drop off area (paperwork will contain date, dept/floor, MR#, specimen type, # of specimens, mislabeled yes/no, time received)

•Develop form that takes less than 1 min to fill out•Begin tracking time specimen received(hemolyzed)•Nurses from IP floors without tube system drop specimens in Lab•Establish Logbook to use due to volume in lab•Determine trends in mislabeling causes•Break data down by department/floor to determine unique problems

Mislabeled Specimen Project

Problem Statement Problem Analysis

Action Items Actual/Proposed Benefits

LMC ED 5s

Since December 2013 LMC and HH ED has had consistency and accuracy issues in ED data reporting parameters and POU systems Pods increasing time on nursing staff to located supplies and reducing staffing by 1 PCT for restocking weekly or bi-weekly and creating confusion from multiple reporting mechanisms/data. This has increased patient time in the ED and decreased stability of accurate reporting for the decision making process of leadership.

•Establish Standards of work for each cabinet in A and B Pods•Sort necessary items from unnecessary (based off daily or emergent use)•Ensure new process is communicated through staff meetings, huddles, memos, and emails•Determine parameters for common cause variation in Business Objects data•Develop queries to quickly analyze 12+ months worth of raw data•Establish phlebotomy tool boxes

Problem Statement Problem Analysis

Action Items Proposed Benefits

ED Admit RIE

Over the past year LMC and HH ED admit wait times from decision to transfer of care are an average of 110 minutes. The goal is 30 minutes. We are exceeding our goal by 80+ minutes, this also creates frustrations for the patients who are waiting for treatment and is reflected in our HCAHPS scores.

•Establish criteria needed on Bridge orders to request bed as well as place patient in hospital•Create a new process narrative for communicating changes•Communicate new process at Dept huddles, BB meetings, staff meetings, staff emails, and charge RN meetings•Create a Process design and complete design paperwork

•Reduction in Admit decision to transfer of care time.•Reduction in Core ED-2a variation.•Improvement of interdepartmental communication.•Improvement in patient information reports.•Sustainment of new process due to frontline staff involvement.•Significant increase in the amount of cases that meet admit decision to transfer of care metric within 30 minutes.

Category As-Is Count As-Is % of process Future Count Future % of

processDecision Point 26 N/A 2 N/AValue Added 9 18.75% 6 37.50%

Buisness Value Added 6 12.50% 3 18.75%Non-Value Added 33 68.75% 7 43.75%

Totals 48 N/A 16 N/A

Problem Statement Problem Analysis

Action Items Actual/Proposed Benefits

STEMI program development

Since Dec 2013, lack of a suitable measuring system to determine system reliability of HHNM Cardiology Department STEMI program has left leadership unsure of the success of the changes made to the process and in many cases if change is necessary. Being unable to report on the success of STEMI program has left revenue producing market places untapped and looking elsewhere for a Cardio services to be provided.

•Establish criteria needed for mission lifeline accreditation•Determine metric gaps •Develop data definitions and formulas for each metric•Build STEMI Dashboard for accreditation and trend analysis•Anticipate future metric needs and build versatility into dashboard system

48 minutes if process goes the easy route174 minutes if process goes the hard route79 Process Steps15 opportunities for failure posing patient safety risk68% of process in NVA, 129 minutes of time in NVA steps

Patient Transport RIEProblem Statement Problem Analysis

Proposed Action Items Proposed Benefits

Since Jan 2015, the patient transportation process at Lovelace Medical Center has lacked proper patient

identification, appropriate risk mitigation for patients being transported, and a “ticket to ride” system. This has impacted the organization by increasing the chances of sentinel/never

events due to lack of standardized/designed processes.

•STAR education – how to prioritize work, edit request, and properly input request•ID cards with all unit phone numbers for Patient Transportation to call prior to arrival•Patient Transportation capacity review (schedule staggering, busy hours vs. procedural department hours)•Procedural staff calls and notifies IP staff/unit when transport request entered •Standardized process for signing out charts•Patients prepped for transport prior to transporters arrival•Transport Manager that coordinates flow of work (Dispatcher)•Personal electronic devices with ability to access/view system (PLT)•List of current days procedures with ongoing updates

•Reduction of patient risk by 80% (15 down to 3)•Improvement of process time by 55% (26 minutes)•Decrease in process range (variation) from 126 minutes and 19 different decision points to 20 minutes and 3 decision points•Eliminated 26% of NVA activities (41 steps to 11 steps)•Reduced total process by 67% (53 steps), 99 minutes of NVA time •Streamlined process for smoother transition and increased awareness of patient care/requirements

Unsuccessful Implementation

Constraints/Barriers:•Lack of structure for Clinical staff•Poor communication plan•Lack of follow through on action items•No data to prove/disprove solutions effectiveness•Changes in Transport Leadership•Changes in SBAR system•Vague measures of success

Mislabeled Inpatient Specimens ProjectProblem Statement Problem Analysis

Action Items Actual Benefits

Since January 2015, 91 of specimens requested for recollect are mislabeled, unlabeled, and/or wrong patient collected

specimens. This increase has affected Lab TAT’s, increase in patient diagnosis/treatment time, incorrect or misdiagnosis or patient, increase in phlebotomy supply usage, reagent cost,

patients lose trust in system. From an organizational standpoint, Lovelace has had an increase of cost of supplies in Lab,

increase in discomfort to patient, Decrease in patient satisfaction, increase in organizational staff friction, loss of

repeat/loyal customers, and loss of staff morale.

•57% of Specimen collection process is required by policy•36% (30 steps, 92 minutes)of Specimen process is Rework•Average of 15 labeling issues per month•Easy route process time = 50 minutes plus test time•Hard route process time = 160 minutes plus test time (125 minutes of rework time)

Labeling issue is categorized as any specimen that is mislabeled, unlabeled, or the wrong patient.

•All labels are separated A person verifies that there is only 1 patient name per biohazard bag(unlabeled specimens, more than 1 Pts per bag, no dt/tm/int)•IP staff checks every lab label against an order(No orders available for specimen)•Determine best solution for scanning the patients armband and having it print all eligible labs labels on a printer close to patients location (specimens labeled with wrong Pts label)

•System now has 8 quality checks to prevent errors (previous system had 3 quality checks)before sending specimens to lab•Reduction in mislabeled patient specimens, wrong label on tube, and unlabeled specimens•Reduction of variation in process by 58% (31 decision points to 18)•Improved in process time range by 34 minutes•Reduction in IP Mislabeled Specimen errors by 43% (from 14 avg to 8)