HMC-Andrea[1]

Introduction : 

Introduction

HMC Demographic : 

HMC Demographic The Harborview Medical Center (HMC) Emergency Department (ED) caters to a diverse mixture of people who need medical attention. HMC is the region’s only level one trauma and burn center and thus cares for a large volume of patients. In addition, HMC is located in a mixed neighborhood and acts as the primary care facility for many of the area’s uninsured individuals.

UW Team Background : 

UW Team Background A system analysis on the HMC ED has been performed by a group of University of Washington Industrial and Systems Engineering (ISE) students.

Project Goals : 

Project Goals The research goals were to: Understand the flow of the HMC ED from the perspective of ED management. Determine parameters of potential projects for ISE Senior Capstone Project*. *Senior Capstone Project is a design group project where students apply their knowledge of Industrial Engineering to actual industry problems.

Methods : 

Methods To understand the flow and process of the ED as well as areas of opportunity, different methods were executed including: Observations Staff interviews Process flow charts, and diagrams (Structured Analysis and Design Technique diagram and Spaghetti diagram).

Observations : 

Observations Regular visits were scheduled weekly. These visits allowed the team to observe the processes closely and to identify the main areas of opportunity that could become potential projects.

Staff Interviews : 

Staff Interviews Sporadic staff interviews were held with nurses, physicians, radiology technicians and technologists, charge and triage nurses, doctors, registration staff, and other medical staff. Some other interviews were scheduled based on the staff availability. Specific questions about the processes were asked during the interviews in order to avoid long interruptions to the staff and let them continue their work.

Structured Analysis and Design Technique (SADT) diagram : 

Structured Analysis and Design Technique (SADT) diagram The SADT diagram created for this project, describes the system of the HMC ED. The SADT diagram is formed by blocks that represent activities. A variety of arrows relate to boxes which give successive levels of detail of the system. Each box has arrows going in different directions which represent constraints, inputs, outputs, and mechanisms in the process.

SADT: Level 1 : 

SADT: Level 1 This diagram describes the process of the system from a high level. Once a patient enters the system and goes through the process, the output will be one of the options represented on the diagram. It doesn’t include any details of what happens through the process of providing patient care. It shows some of the constraints that the process may have while trying to provide care as well as the mechanisms that will ensure a quality care

SADT: Level 1 : 

SADT: Level 1 Capacity

SADT: Level 2 : 

SADT: Level 2 This level represents the processes required for a patient to get care with more details than level 1. It describes every step after the patient has arrived to the ED highlighting the constraints and mechanisms needed.

SADT Level 2 : 

SADT Level 2 Bed queue Bed queue Bed queue Incomplete Need to represent bottlenecks for ALL projects

SADT: Level 3 : 

SADT: Level 3 This level represents the processes required for a patient to get care with more details than level 1. It describes every step after the patient has arrived to the ED highlighting the constraints and mechanisms needed.

SADT: Level 3 : 

SADT: Level 3 Request Queue Incomplete

SADT: Level 4 : 

SADT: Level 4 This level represents the processes required for a patient to get care with more details than level 1. It describes every step after the patient has arrived to the ED highlighting the constraints and mechanisms needed.

SADT: Level 4 : 

SADT: Level 4

Process Flow Chart : 

Process Flow Chart A process flow chart represents every step of the process with symbols and descriptions. It includes the individual’s time, and traveled distance to complete such process. This chart is used to analyze the steps that are causing the main delays. A process flow chart was created to analyze the “Radiology hub” process from its start to the end. It describes every single step required to complete the process and highlights what the major interruptions are.

Process Flow Chart : 

Process Flow Chart

Spaghetti Diagram : 

Spaghetti Diagram A method that uses a continuous line to trace the path and distance traveled of a particular object or person throughout a process. This spaghetti diagram was created to evaluate the travel distance of the nurses when performing supply-retrieval tasks. The diagram realistically represents the actual flow of the nurses performing supply-retrieval tasks and visually represents the unnecessary travel distance.

Spaghetti Diagram : 

Spaghetti Diagram

Projects : 

Projects

Project 1: Streamline Communication : 

Project 1: Streamline Communication The communication between staff in the ED is mainly based on verbal and non-verbal interaction. Verbal communication includes any medium in which the staff communicates: phones, pagers, PA system, face-to-face, etc. Written communication includes electronic and paper. The SADT diagram discussed earlier identifies bottlenecks in various parts of the system. This project will target the following bottlenecks: - Incomplete

Objective and Scope : 

Objective and Scope Objective The objective of the proposed project is to decrease non-value added communicating time by streamlining the information exchange in the ED. Scope The project includes all channels of staff to staff verbal and written communication.

Project Description : 

Project Description Study and analysis of communication channels using industrial engineering tools: Create flow charts of communication process Time study of non-value added communication activities Survey available technology Propose improved methods Prototype and Implement new communication methods

Evaluation : 

Evaluation Accuracy and completeness Duplication of information Average Information transportation time from point/person A to B Rate of unneeded to needed information received by an individual Total communication time compared to direct treatment time

Project 2: Improve Storage System : 

Project 2: Improve Storage System Currently, the storage system is spread across different areas of the HMC ED. There are three main storage rooms, and several secondary storage spaces in each resus room or zone area. Having a non-centralized storage system has its own advantages, such as immediate access to supplies in every room or zone. However, having excess supplies leads to cluttered spaces, and spread out supplies make inventory management more difficult. The SADT diagram discussed earlier identifies bottlenecks in various parts of the system. This project will target the following bottlenecks: The float MA is a bottleneck on the ‘assign room’ process. The float MA spends approximately 10% of their shift traveling to retrieve supplies. Availability of medical supplies in patient care Availability in preparing rooms

Objective : 

Objective Incomplete

Scope : 

Scope Incomplete

Project Description : 

Project Description Study and analysis on choosing a location for the central storage area(s) using industrial engineering tools: Creating an organizational scheme for supplies considering ergonomics. Create and implement a supply tracking. procedure that can improve supply inventory to ensure supply charges are recorded consistently and appropriately. Create a standardized procedure for USTs.

Evaluation : 

Evaluation Incomplete

Benefits and Impacts : 

Benefits and Impacts

Project 3: Maximize Radiology Hub Process : 

Project 3: Maximize Radiology Hub Process Radiology technicians and technologists currently wait for requests forms to be processed by the healthcare information technicians at the Radiology Hub. Processing a radiology request includes: scheduling, scanning, and entering the information in the database. These tasks are currently performed by healthcare information technicians. Once the radiology request forms get processed, radiology technicians and technologists can do the scans and continue providing patient care. The SADT diagram discussed earlier identifies bottlenecks in various parts of the system. This project will target the following bottlenecks: Radiology request forms queue at Radiology hub when healthcare information technicians have to look for physicians or residents to clarify ambiguity on the written requests. Patient’s queue during treatment while they are waiting to bet their scans.

SADT: Level 3 : 

SADT: Level 3 Radiology request form Project #3 bottlenecks Triaged patient Integrate in slide #14

Objective and scope : 

Objective and scope Objective To reduce non-value-added steps and wastes in the radiology request process to maximize the efficiency of the Radiology Hub.  Scope The project will evaluate the process between information technicians and physicians. It will include analysisis of equipment and technology utilized in the Radiology hub.

Project Description : 

Project Description Comprehensive study and analysis of the Radiology Hub process utilizing industrial engineering tools to improve the process: Implement LEAN techniques to identify and eliminate a variety of wastes in the Radiology Hub, such as paperwork and waiting for the scanner to get warmed up.   Thorough process flow charts of the process. Propose and implement improved method. An observation and detailed analysis of the radiology request process at the Radiology Hub was conducted, utilizing industrial engineering tools such as Process Flow Chart. The results of the analysis are represented in the Process Flow Chart. It visually symbolizes every step with its respective time and distance. The process also shows the number of operations, delays, inspections, transportations and storages of the process. This chart identifies and analyzes all the steps that do not add value to the process. The duration of the process is also shown in the chart.

Slide 36: 

The following assumptions were made based on the surveys and interviews conducted with the Radiology Hub personnel: An information technician has to look for the right physician 20% of his/her shift to clarify ambiguity on the paperwork. During summer, this number increases 15% due to the fact that there are a lot of residents in the ED. The scanner has to be warmed up 8-10 times a day on an average day, depending on the demand of radiology requests forms to be processed.

Evaluation : 

Evaluation Average time to process a radiology request form by a healthcare information technician with interruptions and without interruptions. Average time of every interruption in the process. Cost of materials and steps that don’t add value to the system. Physician’s and resident's time spent when being interrupted by the healthcare information technician. Radiology technicians and technologists waiting time (when waiting for radiology requests forms to be processed). Average patient's waiting time to get their scans processed including the radiology request form process.

Project 4: Decrease patient wait times : 

Project 4: Decrease patient wait times Currently Patients who come to HMC ED for emergency medical care regularly wait up to six hours. This project will study multiple ways to decrease this wait time. The length of a patients wait time is most important for the higher acuity patients. This is because their ailments are more time sensitive. This project would also seek to get those high acuity patients through faster.

Objective and Scope : 

Objective and Scope Objective This project analyzes multiple ways to free up bed space and increase the speed in which patients are cured and discharged. The primary objective of performing this project will be seen directly by the patient, through decreasing waiting times. The goal of this project is to open vital bed space so that more patients, with possibly more acute conditions, can be seen immediately. Scope This project will include the emergency departments and Harborview Medical Center. It will exclude the psychiatry department. Only patients of ESI level three, four, and five, will be considered for this proposal. In addition, this project will work with current resources of the ED. No additional space will be added and no additional nurses will be needed.

Project Description : 

Project Description Study and analysis of communication channels using industrial engineering tools -Create flow charts of communication process -Time study of non-value added communication activities -Survey available technology -Propose improved methods -Prototype and Implement new communication methods

Evaluation : 

Evaluation Accuracy and completeness Duplication of information Average Information transportation time from point/person A to B Rate of unneeded to needed information received by an individual Total communication time compared to direct treatment time

Objective and Scope : 

Objective and Scope

Project 5??: Shorten Low Acuity Patient Wait time : 

Project 5??: Shorten Low Acuity Patient Wait time Low acuity patients wait and utilize resources for long periods of time. The SADT diagram discussed earlier identifies bottlenecks in various parts of the system. This project will target the following bottlenecks: Incomplete

Project 6: Zone Assignments : 

Project 6: Zone Assignments The current ED layout places nurse stations at various locations: The front area waiting room Between ED Green and ED Blue The Medicine room The heart of the Emergency Department The flow nurse is in charge of assigning patients to each zone by constantly checking the updated whiteboard. Other than that, the flow nurse has a duty to attend to patients and personally bring them into the Emergency Rooms. As a result, they have to walk around the Emergency Department extensively. Therefore, the layout of the nurse stations would impact the flow and efficiency of the system. This project have direct impact toward the quality of patient care as well as the reduction of non value-adding time contribution within the ED. The SADT diagram discussed earlier identifies bottlenecks in various parts of the system. This project will target the following bottlenecks: Time utilization for patient care (medical staff availability)

Objective and Scope : 

Objective and Scope Objective The objective of this project is to reorganize and determine optimal locations of nurse stations. Scope This project would involve re-organizing the nurse stations and zone assignments in the ED excluding the Psychiatry area.

Project Description : 

Project Description The application of industrial engineering techniques involved in this project would include: Time motion studies Create a Spaghetti Diagram to identify high frequented areas Create Visio diagrams for different layout scenarios Create simulation of the different scenarios Application of Ergonomics criteria

Evaluation : 

Evaluation The following metrics should be used to determine the progress and impact of the project: Travel Distance Weighted Travel Distance: Direct correlation with time Number of Trips: The number of trips it takes a nurse in a particular zone to complete a task in particular zone. Average time to travel from zone to zone

Conclusions and recommendations : 

Conclusions and recommendations List all projects Incomplete

Glossary : 

Glossary Congestion level: A measure of how crowded the path from one place to another is. Healthcare Information Technician: Clerical staff who works at the Radiology hub section and processes radiology requests forms. Lean Techniques: A technique to eliminate non-value added processes and create value with less work. Rectilinear Distance: Travel in the shortest distance possible in a straight line. Resus: Resuscitation room Spaghetti diagrams: A method that uses continuous lines to trace paths, which will show inefficient layouts and/or large distance. ED green: A room in the ED dedicated to patients of ESI Level 3 and 4 ED Blue : A room in ED dedicated to patients of ESI Level 5

Acronyms : 

Acronyms AMR: American Medical Response (Ambulance) DPS: Department of Public Safety (Law Enforcement) EKG: Electrocardiogram - records electrical activity of the muscles of the heart ESI: Emergency Severity Index (Triage) - Prioritize patients based on severity of injury HIPAA: Health Insurance Portability Accountability Act of 1996. A US Law designed to provide privacy standards to protect patients' information PA: Physician Assistant or Mid-levels medical practitioner and supervised by a licensed doctor / Nurses with special training and license. PSR: Patient Service Representative (Social Worker) LWBS: Left without Being Seen - Refers to patient who left before getting treated MA: Medical Assistant - Perform basic clinical tasks under the supervision of a licensed doctor RRF: Radiology Request Form SADT: Structured Analysis and Design Technique. A method to understand flow of a system by recognizing the input, output, constraints and mechanisms STAT: (Statim) Latin word for immediately / (machine) Photostat TTA form: Trauma Team Activation Form - Include trauma patients' info and shows severity UST: Unit Supply Technician - Handles the supplies in the hospital