Kings County Hospital Adopts Toyota Lean Principles to Make Emergency Department More Efficient and Shorten Time Patients Spend in ER
Mar 20, 2012
Bruce Siegel, MD, president of NAPH;
Dr. Yves Duroseau, Kings County
Hospital Center; Caroline Jacobs,
Senior VP, HHC; and Maulik Joshi,
DrPH, editor in chief of JHQ.
Kings County Hospital Center, a member of the New York City Health and Hospitals Corporation (HHC), has been recognized nationally for using Toyota lean methodologies to transform its Emergency Department, improve efficiency and patient flow and shorten the time it takes for a patient to see a doctor. A Kings County medical team describes the improvement process in an article published this month in a special issue of the peer-reviewed Journal for Healthcare Quality (JHQ), which recognizes innovative and evidence-based care efforts at a select number of safety net hospitals across the country.
The journal article, “A Structured Approach to Transforming a Large Public Hospital Emergency Department via Lean Methodologies,” describes a number of successful initiatives adopted by emergency medicine experts at Kings County Hospital to eliminate waste, enhance safety and improve efficiency through the lean method, known as Breakthrough at HHC, during an 18-month period starting in October 2009.
Although the median number of ER patient visits rose 7.3 percent during that period, from 10,867 patients a month to 11,661 patients a month, the total time a patient spent in the ER was reduced by 36 minutes. The amount of time it took for a patient to be triaged was cut in half, to a median of 18 minutes, and the amount of time it took to see a doctor was reduced by 30 minutes.
“HHC has been applying the Breakthrough process in New York City public hospitals since 2007, making quality, efficiency and financial improvement an ongoing and permanent process throughout our system,” said HHC President Alan D. Aviles. “Kings County has done an excellent job in using Breakthrough tools to increase efficiency, eliminate waste and improve the patient and staff experience.”
Kings County was among four U.S. public hospitals recognized on March 15 by the National Association for Public Hospitals and Health Systems (NAPH) and the National Association for Healthcare Quality in Washington D.C. for programs that demonstrate that effective quality improvement measures adopted by safety net hospitals can help address disparities to improve overall patient care and achieve high standards of quality. All four hospitals published articles in the JHQ describing their programs.
Dr. Eric Legome, Chief of Emergency Medicine at Kings County and one of the authors of the JHQ article, said he hopes it will be a resource to other hospital systems in underserved communities. “It gets the word out that what we did makes sense and is worthwhile. If you put in the time, effort and resources you can make rapid and significant improvements in your metrics, flow and finances. This type of strategy is as applicable in a public hospital as it is in any hospital.”
“Limited resources often force creative approaches to implementing best practices,” Bruce Siegel, MD, MPH, president and chief executive officer of NAPH, said at the Washington, D.C. event. “This event is an opportunity to showcase the innovative solutions that safety net hospitals are advancing every day. Their work is improving patient care and enhancing the health of their communities.”
“These studies clearly show that achieving and maintaining high standards of health care quality is not significantly different for hospitals serving underprivileged patients,” said Maulik Joshi, DrPH, editor in chief of the Journal for Healthcare Quality, the official peer-reviewed publication from the National Association for Healthcare Quality. “In fact, the innovative methods used by safety net hospitals to address disparities in care, quality of care and costs of care are timely examples, as anticipated health-reform coverage expansion will bring more underserved patients through hospital doors.”
Kings County has employed lean in various areas and departments since late 2008. In the Emergency Department, the Kings County team conducted Rapid Improvement Events (RIE), a key Breakthrough tool used to identify waste, design new processes and effect immediate change. The team reviewed how patients were being processed in the emergency room, identified waste and redundancy that could be removed to make the process more patient-centered, put the new processes in place, and evaluated the results to ensure sustainment.
Some of the changes made were:
- Registration and triage: A multi-step process for patients to be registered and receive an initial evaluation was replaced by a new model in which most services are brought to the patient and a care team revolves around the patient.
- Radiologic exams: Previously, the ED employed a “push” model, in which patients were sent to radiology by emergency department staff. Changing this to a “pull” model, in which radiology staff retrieves patients, made the process easier for the patient and ensures they obtain the correct service.
- Charge nurse and patient flow: A paper-based patient tracking system was replaced with an existing computerized patient tracking system. Patient call-in, bed check-in, and bed availability, traditionally managed by treating physicians, was transitioned to nursing. Staff was reallocated to create a patient flow coordinator position to assist in these functions, freeing physicians to provide care and treatment.
- A new mid-level provider was posted in triage to enable patients with several common complaints to be more quickly evaluated, treated and released.
In addition to Dr. Eric Legome, other authors from Kings County were: Dr. Yves Duroseau; Dr. Trushar Naik; Dr. Shahriar Zehtabchi; Dr. Stephan Rinnert; Rosamond Payne, RN; and Michele McKenzie. Several authors are available for interviews with news media. Other programs recognized were from Truman Medical Centers, Kansas City, Missouri; Nassau University Medical Center, Long Island; and University of California Los Angeles (UCLA).
Contact : Ian Michaels (HHC) (212) 788-3339
About the National Association of Public Hospitals and Health Systems (NAPH)
NAPH represents the nation’s largest metropolitan hospitals and health systems, which fulfill a safety net mission of providing high volumes of care to low-income individuals. These facilities provide high‐quality health services for all patients, including the uninsured and underinsured, regardless of ability to pay. In addition to functioning as the country’s default national health insurance system, safety net hospitals provide many essential communitywide services, such as primary care, trauma care, and neonatal intensive care. Safety net hospitals also train many of America’s doctors, nurses, and other health care providers. Since its inception in 1980, NAPH has cultivated a strong presence on Capitol Hill, with the executive branch, and in many state capitols. NAPH advocates on behalf of its members on such issues as Medicaid, Medicare, and access to health care services for vulnerable populations. For more information, visit www.naph.org.
About the National Association for Healthcare Quality (NAHQ)
Since 1976, the National Association for Healthcare Quality has served as an essential and interactive resource for quality and patient safety professionals around the world. Over 10,000 members and CPHQs turn to NAHQ for education, research, networking, certification, and resources designed to ease and improve their daily work. NAHQ’s vision is to realize the promise of healthcare improvement through innovative practices in quality and patient safety. Each program, initiative and alliance we initiate reflects our members’ values of excellence, integrity, innovation and collaboration. Visit www.nahq.org to learn more.
About HHC
The New York City Health and Hospitals Corporation (HHC) is a $6.7 billion integrated healthcare delivery system with its own 420,000 member health plan, MetroPlusHealth, and is the largest municipal healthcare organization in the country. HHC serves 1.4 million New Yorkers every year and more than 475,000 are uninsured. HHC provides medical, mental health and substance abuse services through its 11 acute care hospitals, four skilled nursing facilities, six large diagnostic and treatment centers and more than 70 community based clinics. HHC Health and Home Care also provides in-home services for New Yorkers. HHC was the 2008 recipient of the National Quality Forum and The Joint Commission’s John M. Eisenberg Award for Innovation in Patient Safety and Quality. For more information, visit www.nychhc.org/hhc or find us on facebook.com/NYCHealthSystem or twitter.com/NYCHealthSystem.