The Story of a New ED: How Design, Lean Processes and Innovative - - PowerPoint PPT Presentation

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The Story of a New ED: How Design, Lean Processes and Innovative - - PowerPoint PPT Presentation

Dec 30, 2023 207 likes •719 views

The Story of a New ED: How Design, Lean Processes and Innovative Teamwork are Producing Outstanding Outcomes Objectives: 1. Explore benefits of incorporating lean processes into ED design 2. Learn how innovative staff roles, teamwork and team

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The Story of a New ED:

How Design, Lean Processes and Innovative Teamwork are Producing Outstanding Outcomes

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Objectives:

  • 1. Explore benefits of incorporating lean processes into ED

design

  • 2. Learn how innovative staff roles, teamwork and team

workspaces contribute to efficient patient flow and staff engagement

  • 3. List design elements and processes that support the patient

and family experience

  • 4. Describe evidence-based clinical, operational and design best

practices that formed the foundation for a high performing ED

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About the Design Team About Nemours

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Orlando Airport

Lake Nona Medical City

Site

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Site

Emergency Department

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Design Drivers

  • Patient-centered
  • Efficiency
  • Flexibility
  • Quality
  • Technological Innovation
  • Sustainability / LEED Certification
  • Signature Appearance
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Clinics: ¡ ¡Hem ¡/ ¡Oncology ¡/ ¡Med. ¡Spec. PICU ¡+ ¡NICU ¡+ ¡18 ¡Future ¡Beds Dining ¡+ ¡Chapel ¡+ ¡Gift ¡Shop ¡+ ¡Administration Surgery ¡+ ¡PACU ¡+ ¡Preop ¡+ ¡Endo ¡+ ¡IR Neuro ¡+ ¡Ortho ¡+ ¡Rehab ¡+ ¡Surgical ¡Specialties KidsTRACK ¡+ ¡Education ¡Center Clinics: ¡ ¡Neuro ¡/ ¡Ortho ¡/ ¡Rehab Shell ¡Space ¡(future ¡clinics) Clinics: ¡ ¡Surgery ¡/ ¡Neph ¡/ ¡Urology Respiratory ¡+ ¡Pharmacy Roof ¡Garden Public ¡Spaces/Amenities Hematology ¡Oncology ¡+ ¡Medical ¡Specialties Infusion ¡+ ¡Roof ¡Garden

Inpatient Clinics Shared IP/OP Programs & Services

Shell ¡Space ¡(future ¡27 ¡beds) Emergency ¡+ ¡Imaging ¡Services ¡+ ¡Dietary+ ¡CSS Physician ¡Office ¡(Future ¡Clinic)

Model of Care Building Stacking Diagram

Shell ¡Space Lab ¡+ ¡Materials ¡Management ¡ ¡+ ¡Support IP/OP ¡Rehab

1 G 2 3 4 5 6 630,000 GSF

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Design Process

  • Benchmarking
  • Site visits
  • Projections
  • Process maps
  • Family Advisory Group
  • Simulation studies
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Desired Patient and Family Experience

  • Get in
  • Get the care
  • Get out

AND

  • Leave with a “good” feeling
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The LEAN Approach

  • Minimize wait times
  • Streamline processes
  • Reduce staff and patient movement
  • Minimize the number of staff

interacting with the child and family

  • Maximize throughput
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The Staff Experience

  • Pivot RN
  • Dedicated team
  • Streamlined, distinct processes
  • “One-piece” flow
  • Reduced que time between providers
  • One time documentation at the bedside
  • Supplies at the bedside; procedure carts
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The Patient and Family Experience

  • Immediate placement in exam room
  • Provides information once
  • Registers in exam room
  • Interacts with a dedicated team
  • Same exam room throughout visit and

discharge

  • Receives a follow-up phone call
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Ground Floor Plan

Emergency Imaging Central Sterile ¡ Processing

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Floor Plan

Minor Care Entrance Trauma Entrance

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Facility Design

  • Adjacent to imaging services;

sedation rooms contiguous

  • Reception area near Pivot RN
  • Supplies at bedside
  • Bedside computers
  • Rooms accommodate child,

family and staff

  • Internal child life space
  • Team work space
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Simulation Studies

  • Supported reduction in #

rooms, size of reception area

  • Validated provider and nurse

staffing model

  • Corroborated processes, wait

times and length of visit

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Historical NCH ED Growth

R² ¡= ¡0.72859 20 40 60 80 100 120 140 10/22/2012 11/10/2012 11/29/2012 12/18/2012 1/6/2013 1/25/2013 2/13/2013 3/4/2013 3/23/2013 4/11/2013 4/30/2013 5/19/2013 6/7/2013 6/26/2013 7/15/2013 8/3/2013 8/22/2013 9/10/2013 9/29/2013 10/18/2013 11/6/2013 11/25/2013 12/14/2013 1/2/2014 1/21/2014 2/9/2014 2/28/2014 3/19/2014 4/7/2014 4/26/2014 5/15/2014 6/3/2014 6/22/2014 7/11/2014 7/30/2014 8/18/2014 9/6/2014 9/25/2014 10/14/2014 11/2/2014 11/21/2014 12/10/2014 12/29/2014 1/17/2015 2/5/2015 2/24/2015 3/15/2015 4/3/2015 4/22/2015 5/11/2015

Total ¡Visits

Total ¡Visits Linear ¡ ¡(Total ¡Visits)

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Design Supports Innovative Model

  • f Care?
  • Acute Care Model:

Care Streams

  • Swarming
  • Workspaces for

teams

  • Innovations in team
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Acute Care Model

A Framework for Quality Care in Emergency Medicine

  • Care Streams
  • Acuity
  • Degree of diagnostic certainty regarding care needed

*Lyer, S; Reeves, S; Varadarajan, K; Alessandrini, E. The Acute Care Model: A New Framework for Quality Care in Emergency Medicine. A. Clinical Pediatric Emergency

  • Medicine. June 2011. Vol. 12, No.2, pp 91-101.
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How Teamwork Supports ED Processes

ED leaders and staff hired early; rethinking pediatric ED care

Key Ideas:

  • Spirit of continuous improvement
  • Staff empowerment: quality, safety, innovation
  • Best use of technology
  • Patient flow to contact RN immediately;

eliminate long waits

  • Families welcomed and accommodated
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Care Processes: Pivot RN/Paramedic

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Care Processes: Quick Registration/ Rooming

Triage is a process, not a place.

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Standard Room Layout and Equipping

  • Enhances patient safety
  • Enhances staff

satisfaction; staff not searching for equipment and supplies

  • Same-handed rooms
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Innovative Teamwork: Swarming Technique

  • Physician, nurse and medic arrive at the same time
  • Used for code/critical care patients
  • Used for fast track patients
  • Need to have EMR workstations

to support multiple staff simultaneously

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Innovative Paramedic Roles and Teamwork

  • Teamwork ¡with ¡RN’s: ¡pivot ¡desk; ¡in ¡the ¡ED
  • Team ¡deployment ¡into ¡pods
  • Medications
  • Start ¡IV’s
  • Splinting
  • Suturing ¡

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Clinical Pharmacist: Roles and Teamwork

  • 1.0 FTE dedicated to Emergency Department
  • Roving
  • Responds to codes and critical care patients
  • Helps with medication reconciliation
  • Verifies medication orders prior to administration

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Just in Time Stocking/Blue Bin Supply Process

  • Department node with flexible shelving
  • “Every patient” supplies kept in room, at lower par

levels

  • “Frequent use”, but not “every patient” supplies kept

in carts

  • “Low use” kept in carts and totes

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Just In Time Supply

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Procedure Cart and Scale

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EVERYTHING uses a battery

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Outcomes

How are we doing after 4 years?

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NCH ED Outcomes

Outcomes 2013 2014 2015 2016

Left ¡Without ¡Being ¡ Seen 0.1% 0.2% 0.3% 0.3% Patient ¡Satisfaction ¡– Likelihood ¡to ¡ Recommend 91.4 83.7 83.3 81.1 Patient Satisfaction 99% 91% 92% 89% Total ¡Visits 16,318 26,402 33,087 38,585 Length ¡of ¡Stay ¡ (minutes) 84 103 115 127

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Staff Engagement

  • Metrics: turnover, ¡GPTW ¡survey, ¡etc.
  • Processes support staff efficiency
  • Enjoy healthy foods, fitness center,

wellness program

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Staff Quotes

  • “It’s ¡not ¡hierarchical ¡here ¡like ¡other ¡places ¡I’ve ¡worked.”
  • “I ¡can ¡ask ¡physicians ¡questions ¡without ¡being ¡made ¡to ¡feel ¡stupid.”
  • “I ¡feel ¡like ¡I ¡can ¡grow. ¡It’s ¡a ¡good ¡learning ¡environment.”
  • “Probably ¡95 ¡percent ¡of ¡hospitals ¡are ¡not ¡like ¡this. ¡This ¡is ¡what ¡you ¡dream ¡
  • f.”
  • “I ¡was ¡skeptical ¡that ¡the ¡culture ¡was ¡as ¡different ¡as ¡people ¡said. ¡But ¡it’s ¡

true.” ¡

  • “Everybody ¡thrives ¡in ¡a ¡continuous ¡improvement ¡environment. ¡They ¡hold ¡

you ¡accountable ¡in ¡a ¡respectful ¡way, ¡and ¡doctors ¡are ¡held ¡just ¡as ¡ accountable ¡as ¡nurses.”

  • “The ¡biggest ¡difference ¡is ¡that ¡we ¡are ¡an ¡upside-­‑down ¡pyramid ¡with ¡the ¡

patient ¡at ¡the ¡top ¡and ¡management ¡farther ¡down.”

  • “Here, ¡improvement ¡is ¡always ¡paramount.”
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Lessons Learned

  • Flexibility
  • Right ¡function
  • Process ¡vs ¡Place
  • Room ¡size
  • Co-­‑evolution ¡of ¡

technology ¡and ¡ medicine

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Design with Flexibility

Design is informed by

  • Patient Relationship
  • Care Processes
  • Documentation

High Performers Excel Anywhere Design to Empower the Average and Improve the Low Performer

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Form Follows the RIGHT Function

Follow the RIGHT Function

  • Team Communication
  • Access to Resources
  • Access to Patients
  • Access to Workspace

Build flexibility to accommodate volume and acuity

  • Universal Rooms
  • Results waiting
  • Adjacent to ancillary services
  • Adjacent to additional exam space for surges
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Process Versus Place

  • Process ¡is ¡not ¡a ¡Place—triage; ¡registration; ¡discharge
  • Process ¡is ¡not ¡Space
  • Update ¡Supertrack location ¡and ¡flow
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Flexibility: Adapting for Growth

  • Consistent ¡use ¡of ¡Imaging ¡Sedation ¡Rooms
  • Implementing ¡pods
  • Supertrack location ¡and ¡flow
  • Modifying ¡spaces ¡to ¡meet ¡demand
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Floor Plan

Minor Care Entrance Trauma Entrance

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Standard Room Layout/Equipping

  • Does room size accommodate

21st century peds ED care?

  • Built as 120 SF
  • Need to consider number of

people in the room

  • Supporting technology
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Co-evolution of Electronics and Medicine

  • Alcoves with designated equipment parking
  • Telepresence
  • Network and power
  • WOW’s everywhere and for everybody
  • Charging stations
  • Battery chargers
  • Communication Devices
  • Wi-Fi Bandwidth and repeater placement
  • Charging stations
  • What are the walls made of……dropped signals

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ED and NCH Awards and Presentations

ED

  • Florida Hospital Association
  • Lantern Award
  • Presentations on ED processes
  • Healthcare Design Conference 2015

Hospital

  • Leap Frog
  • Press Ganey Guardian of Excellence
  • Florida Hospital Association
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AWARDS

Design – Engineering - Construction

2015 AIA – Georgia Design Award Honorable Mention 2013 Interior Design Best of the Year Finalist- Healthcare 2013 ASLA Florida Chapter - Award of Excellence 2013 AIA - Orlando Design Award of Honor 2013 ENR Southeast - Project of the Year 2013 International Design Award - Honorable Mention 2013 ENR Southeast - Best in Healthcare Project 2013 IIDA Best of the Best Awards - Healthcare 2013 ENR Southeast - Award of Merit for Safety 2013 IIDA Best of the Best Awards - Overall 2013 ABC Central Florida Best Healthcare Project 2011 Modern Healthcare Design Award - Un-built 2013 ABC Excellence in Construction Project of the Year 2010 Bentley Systems Be-Inspired Awards 2013 Symposium Distinction Awards - User-Centered Award 2013 ASHRAE Chapter Technology Award - Central Florida

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2013 LEED Gold

1 of 3 Pediatric LEED Gold Hospitals in the United States

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