Quality Improvement: Implementing Nurse Standard Work in Emergency Department Fast-Track Area to Reduce Patient Length of Stay.

INTRODUCTION: The average length of stay of a fast-track area of a large urban hospital was excessively long, which affected the patient experience and the rate at which patients left without being seen. One approach to reducing average length of stay is to create nurse standard work. Nurse standard work was a defined set of process and procedures that reduce variability within a nurse's workflow. METHODS: Nurse standard work was created by a team of nurses assisted by management engineering using lean methodology and A3 problem solving. Data were gathered about average length of stay and left without being seen for patients in the emergency department fast-track area of an urban emergency department from October 2018 to June 2020. This period includes 5 months before the intervention start, 4 months during nurse standard work implementation, 9 months using nurse standard work before the unit was repurposed during COVID-19, and 3 months during COVID-19. RESULTS: Nurse standard work helped reduce average length of stay in the emergency department fast-track area from 205 minutes before project initiation to 150.4 minutes in the 7 months after implementing nurse standard work. The time spent walking for supplies was reduced from 422 and 272 seconds before nurse standard work to 25 and 30 seconds for the nurse technician and nurse, respectively, after nurse standard work. Left without being seen was decreased from 4.7% in October of 2018 to 0.7% by March of 2020. DISCUSSION: Nurse standard work reduced the amount of time that nurses spent performing support tasks and reduced delays in providing patient care, which then allowed more time for nurses to interact directly with patients. Nurse standard work provides a clear task sequence that eliminates delays in treating patients, but it also allows for fast identification of delays that do occur and simplifies problem solving to eliminate reoccurrence of delays. Therefore, nurse standard work is an essential component of efforts to reduce patient average length of stay in health care processes and reduce left without being seen to the national standard of less than 2%.

Simulating the effects of operating room staff movement and door opening policies on microbial load.

OBJECTIVE: To identify factors that increase the microbial load in the operating room (OR) and recommend solutions to minimize the effect of these factors. DESIGN: Observation and sampling study. SETTING: Academic health center, public hospitals. METHODS: We analyzed 4 videotaped orthopedic surgeries (15 hours in total) for door openings and staff movement. The data were translated into a script denoting a representative frequency and location of movements for each OR team member. These activities were then simulated for 30 minutes per trial in a functional operating room by the researchers re-enacting OR staff-member roles, while collecting bacteria and fungi using settle plates. To test the hypotheses on the influence of activity on microbial load, an experimental design was created in which each factor was tested at higher (and lower) than normal activity settings for a 30-minute period. These trials were conducted in 2 phases. RESULTS: The frequency of door opening did not independently affect the microbial load in the OR. However, a longer duration and greater width of door opening led to increased microbial load in the OR. Increased staff movement also increased the microbial load. There was a significantly higher microbial load on the floor than at waist level. CONCLUSIONS: Movement of staff and the duration and width of door opening definitely affects the OR microbial load. However, further investigation is needed to determine how the number of staff affects the microbial load and how to reduce the microbial load at the surgical table.

Perioperative workflow: barriers to efficiency, risks, and satisfaction.

An in-depth, interdisciplinary case study was conducted to map and describe the information, material, and functional processes common to high-volume surgical specialty procedures at a southeastern US hospital. Researchers identified process defects and their effects using both observation and staff member interviews. Outdated information and structural barriers to communications were responsible for many procedural delays, procedural interruptions, and staff member work-arounds. Opportunities for improvement are identified, including redesigns and enhancement of information technology systems.

Assessing operating room turnover time via the use of mobile application.

BACKGROUND: Improving operating room (OR) utilization is crucial to hospitals. This study examines the effectiveness of a mobile application co-developed with hospital staff to track OR turnover time (TOT). METHODS: An Android-based app, named ORTimer, was used by staff in two OR units (GI-Lab and D-Core) of Greenville Memorial Hospital (GMH) in South Carolina. The staff used the app to record milestones and note delay reasons (if applicable). A total of 1,782 turnover observations from the GI-Lab and 694 turnover observations from the D-Core were collected for the study. Using data collected from the app and additional information from GMH's electronic medical record system, a two-sample proportionality test was conducted to test the hypothesis that the use of the app improved OR turnover performance (i.e., the TOT is equal to or less than the allotted time). RESULTS: The result of the hypothesis test indicates that a higher percentage of observations in the GI-Lab and D-Core met their turnover target time when the ORTimer app was used. Additionally, multiple regression analysis was used to identify significant factors that contribute to prolonged OR TOT and to estimate their impacts. CONCLUSIONS: The app serves as both a visual management tool as well as a TOT data collection tool. By identifying barriers to the on-time completion of the turnaround, the app allows for continuous improvement of the turnover process.

Rethinking behavioral health processes by using design for six sigma.

Clinical evidence-based practices are strongly encouraged and commonly utilized in the behavioral health community. However, evidence-based practices that are related to quality improvement processes, such as Design for Six Sigma, are often not used in behavioral health care. This column describes the unique partnership formed between a behavioral health care provider in the greater Pittsburgh area, a nonprofit oversight and monitoring agency for behavioral health services, and academic researchers. The authors detail how the partnership used the multistep process outlined in Design for Six Sigma to completely redesign the provider's intake process. Implementation of the redesigned process increased access to care, decreased bad debt and uncollected funds, and improved cash flow--while consumer satisfaction remained high.