University of Twente Student Theses


Need for speED:interventions to reduce patients length of stay in the emergency department of Isala Klinieken

Grootevheen, Jeanine van de (2009) Need for speED:interventions to reduce patients length of stay in the emergency department of Isala Klinieken.

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Abstract:“More efficient, transparent and innovative hospitals can be achieved by introducing business and logistic perspectives in the health care sector” (TPG, 2004). Motive In Isala Klinieken, the emergency department (ED) observed an increasing demand for emergency care in 2007, resulted in long waiting times, a need for increasing capacity and dissatisfied patients in the emergency department. To cope with these changes, the patient length of stay (LOS; time from enter until departure in the ED) has to be improved. Since residents, ED-nurses and specialists in the hospital give various causes for a long patient length of stay, the management realised more quantitative insight is needed into the process and activities in the ED to be able to suggest length of stay improvements. This research focuses on patients of general surgery (including traumatology patients) and internal medicine, who together represent 91% of the total patient visits in 2008. These patient groups both have representatives of specialists and residents working in the ED. Objective Isala Klinieken wants to reduce the patient length of stay, hence the objective of this research is ‚to suggest interventions to reduce patient length of stay in the emergency department by mapping all the processes assess the duration of separate processes and activities and analyse inefficiencies”. Research Questions To accomplish the goal of this research, the research is split in the following parts: First we use a general system approach to analyse the main components of the ED: input, output, patient flow, resources, planning and control structure and current patient length of stay of the ED. Second, with input of manual measurements the research measures the duration of processes and activities. Third, part gives a conclusion of this quantitative analysis that explores inefficiencies in the process using lean management philosophy, capacity management and manufacturing theories. Finally, literature and analysis are combined to propose practical interventions to reduce patient length of stay. Extensive Analysis This research provides an extensive systematic analysis of the ED from a logistic perspective with a general system approach. This means that the ED is a black box that uncovers quantitative data of patient in- and outflow. When opening the black box, we follow patients who have their own process path in the ED. During this process they use resources, like staff and beds, until they leave the ED to home or to other departments of the hospital. Various steps in the process represent workstations or activities that add or do not add value to the patient in the process. This research gives an in-depth description of all these processes and activities. Measuring the duration of activities and time between these activities in the process leads to a quantitative and objective overview of the ED. The description is enlightened with an extensive analysis of the planning and control structure of the ED, available resources and the patients length of stay. Furthermore, the availability of staff in the ED is plotted to the demand of patients arriving for every hour of the day. Unbalance between capacity and demand is Need for speED 2 revealed, together with the most inefficiencies from a logistic perspective with lean management and manufacturing theories. Results When combining the extensive analysis into conclusions with a logistic background, we conclude the following: The ED is a complex process with unplanned patient arrivals and unknown care paths through the ED. When a patient enters the ED, all the steps of care are unknown because decisions about these steps (care path) are taken by staff later in the process. Depending on the needs and results (of diagnostics), the care path of a patient changes within the process. The decision about this path is postponed to the time a resident has these results. Therefore important processes start after each other (e.g. steps before a patient is admitted), instead of parallel towards each other. Not only the decision is postponed, but also the needs of the patient are postponed to the time the resident is available. When a patient enters the ED the main goal is to get a consult of a resident. In general, the demands of the patients do not determine the process in the ED. Currently, they cannot be segmented by their needs in the process, and they are segmented by their urgency. Every patient follows the same (unstructured) process in the ED, where they enter separate queues with an unspecified waiting time. Staff in the ED (especially residents) work on many patients at the same time, since they are scarce they divide their time over all patients in the ED. This staff only performs work on one patient at the time, while the other patients are waiting and no activities are performed for them. These issues imply a high work in process. An increase in work in process leads to an increase in patient length of stay. Another problem with the unavailability of staff is that the working schedules of residents unfit arriving patient demand. The number of patients arriving in the ED changes every hour. In the analysis, time-slots of high patient demand were found where fewer residents were available than in hours of low patient demand. Also the capacity of the radiology modalities and capacity of nurses in the nursing departments does not fit the demand of emergency patients. These conclusions result in four main areas of inefficiency in the ED for which this research describes practical interventions. The practical interventions focus on improvements of early decision making and information availability, parallel processes, reducing number of patients in process, fit capacity to demand and a process oriented approach where the needs of the patients determine the process. Recommendations We recommend to benchmark the performance of the current situation of the ED three-monthly with new statistics and performance figures to check the following parameters: length of stay (departure, admission patients), number of patients per time-slot of the day, number of admissions, hours of admission, triage times, time to residents’ anamnesis, time from anamnesis to departure. The current data-warehouse system is able to present and measure these parameters. For other parameters the current system is unable to present useful measures: recording request time of diagnostics and time of results available. We recommend extending the electronic patient record in such a way that it stores data and numbers of these performed diagnostics result times. With that the ED can extra measures the queues a patient enters and waste time between result and further action. With every performance check, the ED finds inefficiencies and can compare these with earlier performance and patients in- and outflow. This benchmark should be routine for the management to control the performance and Need for speED 3 problems of the ED. A further step is to implement a performance board for ED-nurses and residents to keep track of their work and involve them in performance, problems and decision making. Further research This research provides an extensive analysis with quantitative and qualitative data of patient flow in the ED. The ED can use this analysis to carry out a simulation study to measure the impact of future developments (exploding self-referrals, the impact of emergency residents in the ED and merge of two emergency departments into one) on the performance. With a model of the ED, the (expected) arrival of patients, utilisation of staff and rooms, various waiting times (e.g. from enter to anamnesis) and length of stay, the management of the ED is able to make decisions how to cope with this future changes in the organisation of the ED.
Item Type:Essay (Master)
Isala Klinieken
Faculty:BMS: Behavioural, Management and Social Sciences
Subject:85 business administration, organizational science
Programme:Industrial Engineering and Management MSc (60029)
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