The Company Profile
Sentara Healthcare is acknowledged as a leader in patient safety and quality care innovation, which continues with the multi-year implementation of Sentara eCare®, a comprehensive electronic medical record. Founded in 1888 as the Retreat for the Sick in Norfolk, Virginia, Sentara has been ranked for more than a decade among the nation’s top 10 most integrated healthcare systems by Modern Healthcare magazine. Sentara, a not-for-profit health system, operates more than 100 sites of care in Virginia and North Carolina including seven hospitals, rehabilitation and advanced imaging centers, ambulatory campuses and a 380-member medical group, home care and hospice services, medical transport ambulances and the Nightingale Regional Air Ambulance. Optima Health, Sentara’s award-winning health plan serves 380,000 members.

The Situation
Sentara Healthcare’s Reinventing Department recognized the challenges of supporting a culture of continuous improvement in the healthcare environment while focusing on the quality of care. Sentara wanted to incorporate the Lean tool set as part of their standard improvement methodology to facilitate rapid change. They requested assistance from Old Dominion University Business Gateway (ODUBG). ODUBG is a service delivery party of GENEDGE ALLIANCE.

Sentara Norfolk General Hospital (SNGH) had the need to increase Emergency Department (ED) capacity to meet its ever-growing patient demand. The emergency room consists of 42 beds, 2 trauma bays and 5 critical care beds. They were chosen as the pilot unit for they system.

SNGH leadership sought assistance in reducing emergency room wait times after the decision to admit the patient had been made and a bed was available. At the start of this project, emergency room wait times after admission varied greatly with delays up to 16 hours. This project focused on the time between the assignment of a ready bed to the time the patient arrived on the nursing unit. Delays in patient departure were directly linked to reduced emergency room capacity, increased wait times for incoming patients, and patient satisfaction.

The Response
The team was comprised of frontline staff. Nurses from the ED and inpatient nursing units, registration personnel, Environmental Service Department (ESD) as well as bed flow coordinators (nurses) were recruited to identify causes and solutions of the problem. After initial Lean Principles and Value Stream Map training by ODUBG, the team created their own value stream map of the bed flow process. The “current state” value stream map allowed the team to identify numerous constraints that prevented the patient from departing the emergency room within the stated goal of 60 minutes or less. Creating the map as a team provided an opportunity to better understand the internal customer/supplier relationships in the bed flow process and the expectations associated with those relationships, improving communication and decreasing employee frustration.

Next step for the team was creating a "future state." This is a value stream map for their bed flow process and a prioritized action plan to close the gaps between current and future states. The team continued to meet bi-weekly working between meetings to complete action items. Issues addressed by the team included the timeliness and accuracy of information flow and absence of a standard process. Although reducing the overall process cycle time (patient assigned a ready bed to the patient being in the bed) was the team’s goal, they established a target of 60 minutes from ready bed assignment until the patient is bedded as the key metric. This was the only part of the bed flow process completely within the team’s control. (Variability in physician practices was outside the scope of this project). Prior to implementing any improvements, only 18% of the patients admitted from the SNGH ED were in hospital beds within this target time.

Improvements to the bed flow process included:

• Redesign of the patient transfer fax report.
• Improved information accuracy to bed flow coordinators, allowing bed assignments to be made correctly "the first time."
• A standard process was created and visual job aids were implemented, creating defined inputs and outputs for each process step and eliminating redundancies and non-value added tasks.
• ESD resource allocation and process were adjusted to allow prompt room turnover between patients.
• Allocation of mobile phones for charge nurses to ensure prompt and concise communications.
• Commitment by the Lean representatives to work together to resolve issues related to the new process included a 24-hour turnaround on the investigation of process issues and a report of the actions taken.
• In March 2009 SNGH transitioned to their electronic medical record (EMR). Prior to implementation the team developed an algorithm to educate staff on an electronic report that replaced the faxed report, facilitating a smooth transition to EMR.
• In June 2009 an ESD module that interacts with the EMR was implemented that increased the transparency of ready beds.

The Results

• Five months after baseline, 29% of patients were bedded within the targeted 60 minutes. One year after baseline, this had improved to 68%, an improvement of 50% from baseline.
• Increased capacity allows the emergency room to see more patients without affecting the quality of patient care.
  The SNGH emergency room was ranked #1 in patient satisfaction among all of Sentara’s other hospitals.
• Project results were used to assist SNGH in attaining Magnet Status.
• Creation of an atmosphere of teamwork and employee satisfaction.
• A new foundation for a culture of continuous improvement.
• The success of this project also led to similarly successful efforts at Sentara Healthcare’s other hospitals. ODUBG continues to team with Sentara’s Reinventing Department as a resource for Lean training and project implementation assistance.

Leadership's Comments
"ODUBG's assistance has resulted in SNGH’s ED meeting, sustaining and improving on their goal of 60 minutes to less to an assigned bed out of our ED. This small process change has benefited many stakeholders. The patients and families have benefited most of all as their admission from the emergency room has decreased in time. It has had the additive effect of improving overall workload in the ED and thus we are also able to care for and discharge other ED patients quicker and have shorter waiting room times. Finally it has also benefited our staff who through the process of redesigning were able to decrease non-value added work and improve communication between departments, with our current work environment in healthcare we need to spend more time helping our staff work smarter and streamline efficiencies. The success of this project has ensured that we will use this tool in the future and are considering how we make this a part of every manager's toolkit." -Jennifer Burrows, Vice President Operations / Patient Care Services, Sentara Norfolk General Hospital