“We created a system that brings services to the patient instead of the patient having to go to the services.”
- Karen Gifford
In 2011, Virginia Mason opened a state-of-the-art Emergency Department that was like few EDs anywhere in the nation. The opening came after years of study and planning in the previous department where VM teams applied a variety of Virginia Mason Production System tools to design a unit that put the needs of patients before all else – and in every way.
The new ED, located in the Floyd & Delores Jones Pavilion, stands as a singular achievement in Virginia Mason’s pursuit of the perfect patient experience. We’ll talk more about this unit in future blogs but today we are focusing on key elements that are foundational to the ED functioning at the highest possible level of quality, safety and access.
For decades, the issue of time has been a bedrock problem in emergency care. Traditionally, patients wait at every turn and it is not uncommon to hear of waits of many hours to be seen by a provider.
The experience at our new ED is totally different. When patients arrive, they are greeted by a nurse who assesses their acuity level. This is done using an Emergency Severity index scale of 1-5* (1 being the most acute). The nurses are so well trained and experienced in emergency medicine that they often make their assessment (based on how the patient presents and his or her chief complaint) in minutes and sometimes seconds.
During the recent years’ improvement work, various kaizen events showed that flow in the ED could be improved significantly (and wait times reduced in a big way) if patients with relatively straightforward conditions were treated in an area set apart from the ED.
Rapid Medical Evaluation Area
Virginia Mason created a separate physical area consisting of four rooms where patients in the 4 and 5 categories are treated right away. “One concept from our VMPS work was to not have patients penetrate further into the ED than they needed to,” says Karen Gifford, RPh, administrative director, Emergency Services. “So when patients with lower acuity go through our rapid medical evaluation area, they get seen quickly, get the care they need and leave in a much shorter amount of time.”
Here was but one example where the voice of patients – who were involved in the redesign of the ED throughout the process – made a difference. Initially, the triage area was called the “sort area” by clinicians, but patients didn’t think that sounded quite right; it seemed dehumanizing. So the name was changed to better represent what actually took place – the Rapid Medical Evaluation Area.
Bring Services to Patients
During the course of the design process for the new ED, VM teams – working closely with patients – came to understand that a major stress point for patients was leaving the Emergency Department to travel to other areas of the hospital for services.
“We created a system that brings services to the patient instead of the patient having to go to the services,” says Karen. “We now have a CT scanner located in our ED and expanded our lab services. Before, especially for patients with strokes and high acuity needs requiring a CT, it meant having to leave the department, travel down a hallway, take an elevator ride and often wait. It was stressful for them.”
Quiet Zone for Team
Whether nurses, doctors, technicians or those in any number of other roles, ED team members are exposed to a non-stop flow of urgent, often immensely challenging, medical conditions. They never know what will come through the doors or when. They just know it will be a challenge.
The stress of these positions is considerable. As part of our commitment to putting the patient first, we created a quiet area so team members can get a break and reenergize to take the best possible care of patients.
“This space for the team is separate from the clinical area, and it is a nice quiet zone where they can eat or read or just unwind for a bit,” says Karen. “The team’s reaction has been wonderful. There are big windows with natural light and it is very rejuvenating. They work so hard they need to be able to go somewhere close to the work space but that lets them feel like they are away from it. It is really important that team members have time away from daily stress and mental fatigue.”
There are many measures of effectiveness in the ED but among the most important is patient satisfaction. On that score, Virginia Mason’s ED rates a 90-percent-plus satisfaction score through Press Ganey.
Another measure involves time – how long it takes to discharge patients to home or to admit them to the hospital. (On average, about 70 percent of ED patients are discharged home while about 30 percent are admitted to the hospital.)
As recently as the start of 2013, the average amount of time patients spent in the ED before discharging home was 191 minutes. Through the use of Rapid Process Improvement Workshops and other VMPS techniques, that is now down to 171 minutes. For patients admitted to the hospital, the time at the start of the year was 263 minutes and is now down to 233 minutes.
Virginia Mason has been able to accomplish this with a new ED that has fewer beds – yes fewer beds – than the previous unit. It has done so because the VMPS techniques used – including crucial patient input – has created a much more patient-centered and efficient ED – among the finest anywhere.
*For example, while a heart attack would be a 1, a simple abrasion on the arm would be a 5. A patient presenting with a lot of gastrointestinal pain, nausea and general malaise would be a 3 (and could be sicker than how they appear).