Prospective projects were studied as the project

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sustainment phase. Prospective projects were studied as the project occurred (i.e., from the initial training and project implementation to sustainment). Emergency Department Value Stream Projects (Retrospective) The ED value stream included a number of RIEs for study. A hospital executive said one of the motivators for improving the ED value stream was an incident in a neighboring county hospital in which a patient died in the ED waiting room. Lean projects in the ED value stream began in January 2009 and continued through our second site visit in October 2010. Project Goals The goal of the ED Value Stream projects was primarily to create efficiencies in the department and improve clinical practices. The specific goals were to: Improve efficiency of triage and identification of resources needed through to ED disposition. Reduce patient wait times. Reduce the number of patients leaving without being seen. Decrease number of charts open at a given time. Create a standard work process for patients presenting with abdominal pain. Remove duplication of effort. Improve workspace organization. Improve billing and medical records processing. Encourage hand washing. Improve pain management. Eighty-seven percent of our admissions come from the emergency room. So, getting the flow through the emergency room smoothly is a major issue. We've made major strides but there are also major issues.” Senior executive “The most difficult time we’ve had so far is the emergency department because their volume is unpredictable. It’s easier to do things with patient flow. The emergency department, one of our TPOC metrics is getting patients through the system quickly. It starts in the emergency room.” Senior executive
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184 The following projects that were part of the ED value stream were mentioned in documents supplied by Heights or by interviewees, but detailed information was not provided: Triage system change. Triage system change: Convert from Canadian Triage and Acuity Scale system to the Emergency Severity Index (ESI) triage system. Cycle time for patients, primarily women of childbearing age with abdominal pain. Time reduction for urgent care patients to be seen by a doctor. Nurse workstation and code area organization. Chart billing and scanning enhancement. Discharge process improvement. Pain management improvement. Implementation Site: Emergency Department The value stream focused entirely on the ED, which is headed by a physician, as the chief of service, and a nurse manager. There are approximately 40 beds, but only 11 rooms in the department for evaluating and triaging patients. The ED is located in a cramped space, and patients are sometimes placed in common areas when no examination areas are available. In addition to emergency care, the department includes an urgent care service, known as Express Care, which treats walk-in patients with minor emergencies.
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