In the aftermath of a tragic death and legal settlement, Kent Hospital created a new approach to its emergency department procedures – including an end to the practice of diverting ambulances. That new process was designed in partnership with Ximedica of Providence.
Providence Business News asked Kristin Simoens, director of healthcare delivery solutions at Ximedica, to share the process of what happened.
PBN: In the aftermath of the settlement of lawsuit of Michael Woods’ death in the Kent County emergency room, Ximedica was hired to help create a new process at the hospital for handling emergencies. What was Ximedica’s approach?
SIMOENS: Ximedica’s Healthcare Delivery Solutions Division began its partnership with Kent Hospital’s emergency department staff in 2010. Our approach is heavily steeped in the science and art of human factors, which manifests itself into human-centered workflows and processes in the healthcare setting.
The fundamental premise in which we work from with all of our hospitals is that health care systems are complicated, non-linear webs of interactions. Our job is to work with our clients in deconstructing, analyzing, and reconstructing solutions that are safe, simple, and human-centered.
Initially, we spend a great deal of time benchmarking and shadowing the staff, and then spend a considerable amount of more time looking at how can we evolve best practices from inside and outside the health care industry to deliver improved systems and processes to each unique workflow design.
While we employ some of the more conventional methods of today that focus on cutting waste and standardizing as much as possible (e.g. lean, six-sigma), experience tells us that you need to go beyond these tools. Standardization takes the mystery, the variability, and the subjectivity out of a process so you inherently end up with more consistent, reliable, and repeatable systems.
The problematic oversight with standardization is that you can’t take the variability out of people – the people who give and receive healthcare. So, tools like lean only get us so far. Redesigned workflow solutions need to anticipate and account for variability among the people who need to perform the task – variability in skills, experience, perspective, cognitive awareness, and situational differences. Ximedica refers to these collaboratively built concepts as “human-centered solutions” – which translate into adoptable, sustainable, and flexible solutions for future growth and evolution.
PBN: How did Ximedica support Kent in its process to improve safety in their Emergency Department?
SIMOENS: Right from the start, Ximedica and Kent’s emergency front line staff formed a close working team. Our first task was to deconstruct and map the complete patient journey of emergency department care starting from the time patients walked through Kent’s door until the time they left – either as an in-patient admission or discharge.
All of the interactions of the “workflow web” were studied and documented – how staff interacted with their tools and technology, with their environment, with each other, and most importantly, with their patients).
This comprehensive snapshot of the entire patient journey was then used to identify the most risk prone elements of the system – breakdowns in communication, work-arounds, inconsistencies, and overall frustrations.
With a true understanding of “real issues and problems” vs. “perceived issues and problems,” we were able to gain alignment on critical areas of opportunity for change.
Our first project focused on improved communications and workflow within the various treatment areas of the emergency department. Subsequent to completion of this first initiative, a problem familiar to most hospitals – long wait times and overcrowded waiting rooms – presented itself as the next top priority.
In designing the Rapid Assessment model, we utilized rapid cycle tests for change throughout the process. The test, refine, re-test mentality kept the process evolving into something better and better with each passing day and sometimes with each passing hour. This is a real testament of the commitment to success on behalf of the Kent ED staff and leadership.
PBN: The new Rapid Assessment model for the Kent Hospital emergency department, with a pledge not to divert ambulances, is now in place. What other quality measurements will be used to benchmark the results?
SIMOENS: Of course, you can only manage it if you can measure it – so yes, historical metrics are very important for ongoing process improvement, but real-time data is equally important. The ability to be proactive and identify potential problems or process drift will trigger corrections before breakdowns occur – like having to go on diversion.
Key metrics that will be used going forward include:
PBN: How soon will these innovations and changes be adapted by other hospitals in Rhode Island?
SIMOENS: Ambulance diversions cause inefficiencies and potentially unsafe practices across the state. Ultimately, patients are seen at hospitals that may not have immediate access to their history or established care providers. Already-scarce EMS resources are pulled out of their home communities to other hospitals, sometimes putting other emergency departments at risk.
The good news is that Rhode Island is replete with excellent doctors and nurses that simply need to be working within the framework of an improved process – similar to where Kent started. There is no silver bullet, and it’s a lot of hard work to achieve and maintain because there will be those days when nothing goes right. Kent continues to make small adjustments daily. The ability to learn from what they did is a real opportunity for other hospitals to make “no diversion” an expected standard of practice.
PBN: What are the lessons that other businesses can learn from this process?
SIMOENS: Number one, front line staff empowerment and engagement gives you the best chance for success. Number two, management buy-in and support are non-negotiable – if you don’t have it, don’t bother.
Everyone is all too familiar with that defeated feeling that there are so many broken and siloed pieces and parts that nothing will ever get fixed. Altruistic attempts at providing work-arounds or band-aids often either complicate the situation even more or eventually are written off as the “flavor of the month.” Top-down approaches never fully get to the root of the real problems, and bottom-up tactics usually end up taking a back seat to the day job at hand.
Design and development groups like Ximedica don’t have all the answers. As clichéd as it may sound, the answers typically lie within the client organization. It’s the process that organizes and facilitates the vision and sharing of best practices, and the ideas of several individual stakeholders, who are on the front lines everyday that ultimately will define and execute change, and given support and time, will lead to a transformational difference that moves the needle.
Financially speaking, high human-touch environments like hospitals see a quick return on their investment by focusing on redesigning internal workflows that position them to better receive and care for their current volume of patients as well as expected growth in volume. It is absolutely the most fiscally responsible way to make a positive impact fast, without the need for investment in capital or new technology.
