Amanda Mewborn of Perkins+Will worked with a client on to understand process changes in the emergency department of a hospital, and used analytics to determine the impact of those process changes on the physical space.
A large community hospital with more than 100,000 emergency visits annually struggled with patient waiting times, and decided to make some drastic changes to the process used to care for patients. The initial perception was that the hospital lacked space to care for all of the patients, as all exam rooms and the waiting areas were occupied during peak times. The department operated as four entities: Children’s Emergency Center (CEC), Fast Track (FT) Main, and Observation. The CEC cares for all pediatric patients, while the other three areas care for adults. FT is for simple medical issues, Main is for complex medical issues, and Observation is for patients that need to be observed further, but do not need to be admitted to the hospital.
FT, with the shortest turn-around-time for patients, at less than two hours, was targeted for improvement. If more patients could be seen in the FT area, space would be freed up in the other areas, patient turn-around-times would decrease and patient and staff satisfaction would improve. The team decided to dedicate five triage rooms and three recliners in a hallway. Quickly, even this small area became overwhelmed, and the team identified that many more patients could be seen in FT, if only there was more space.
Analysis of the Process in the Existing Space
The team toured the existing space, learning about the current processes, and visualizing the spaces, how they are currently utilized and the barriers created by the existing space. The team then met with several members of the department to understand and map the current workflow. Additionally, challenges currently encountered in the process were highlighted with yellow bursts. The swim lane format was used for the process map. A sample of the process maps developed is featured below:
Analysis of Possibilities for the Future State
Next, the team imagined a future state where many more patients could be cared for in FT. When envisioning the future state, the team utilized Lean principles, such as the elimination of waste, delivering more value to the customer in less time, and 5S for organization of spaces. The future state reflects an ideal, or utopia of sorts and was documented as process maps, assuming space and staffing wouldn’t be an issue. Again, swim lane maps were utilized, with the swim lanes representing physical spaces. A sample of the future state process is shown below:
Analyses and Simulation
Next, the team analyzed patient volumes and the impact of shifting care of patients to various areas of the department. The first step in the analysis was to identify how many patients are in the ED at any given time of day. This analysis demonstrated that the facility might need 71 spaces (including Waiting Areas) to care for Adults and 16 spaces (including Waiting Areas) to care for Children with current volumes. Next, the same analysis was completed for FT patients. This analysis suggested that seven spaces are needed to care for current FT patients, and that the existing FT space (five rooms + three recliners) is unable to accommodate any additional patient visits.
Data provided on patient visits that could qualify to be seen in FT (if there was capacity) was reviewed. The daily FT volume in its current state is 52 visits. There were 122 additional visits per day identified that would qualify for FT if there was space capacity. This represented a 235% increase in daily patient visits to FT, to 174 visits per day. The analysis suggested that 24 spaces are needed to care for the proposed FT patient visits.
Certainly, shifting 122 visits per day from care in Main and CEC to FT would have an impact on the space needed by CEC and Main. Creating additional care spaces for FT would result in reduction in existing rooms in Main and CEC. The analysis demonstrated 241 hours of additional patient care per day that would take place in FT. This resulted in 10 additional FT spaces needed to accommodate the additional patient visits.
The next step was to identify the reduction in spaces needed in Main and CEC for patients that would now be cared for in FT. The analysis showed that 527 hours of patient care each day would no longer take place in Main and CEC. This resulted in almost 22 Main and CEC spaces that would no longer be needed.
Based on this cursory analysis, it is suggested that if the ED would like to shift patient visits from care in the Main and CEC to FT, the ED will need to add 24 more patient care spaces in FT to provide an additional 241 hours of care each day. Further, it is estimated that the ED may need 11 to 22 fewer patient care spaces in Main and CEC to provide 527 fewer hours of care each day.
Potential Architectural Design
While the current state, future state, analyses and simulation were taking place, architects designed a new Fast Track that alleviated the pressure on the Waiting Area and addressed many of the challenges identified in the current state process map. The initial design was completed before the analyses and simulation; therefore, some changes will be needed. For example, more FT care spaces or rooms will be needed. However, the drawing is a great visual for the clinical team to imagine the possibilities.
We are still actively engaged with this client, helping them to determine next steps on both the analysis and design. The client is trialing the future state process in their existing space for two weeks to test the change before proceeding with bigger changes to the physical space.
Amanda Mewborn, RN, CPN, CPHIMS, PMC, DSHS is a senior healthcare consultant with Perkins+Will where she assists clients with improving operational efficiency, patient experience and quality.