North Carolina covers 48,711 square miles, with a 2016 estimated population of 10,146,788 people – with 2,206,740 people living in rural North Carolina. There are 113 hospitals in North Carolina (Kaiser, 2015), 21 of which are identified as Critical Access Hospitals. These 21 hospitals literally span the length of our state – from Murphy to Nags Head.
Debbie Hunter, Performance Improvement Specialist with the NC Quality Center, leads a Quality Improvement Collaborative for Critical Access Hospitals in the state which is funded through the FLEX Program and administered by the NC Office of Rural Health. Debbie visits with each hospital in the Collaborative on a regular basis to provide ongoing support to their improvement activities. An added benefit to these visits is the discovery of gems of innovation at these small hospitals. On a recent visit to Murphy Medical Center in Murphy, staff shared a unique and special way they are addressing the needs of behavioral health patients.
Murphy Medical Center was experiencing long lengths of stay and waits for patients in the Emergency Department (ED). Patients needing behavioral health services were occupying beds in the ED for days at a time. This decreased the number of beds available, thus slowing down the flow of all patients through the department. The decision was made to expand the ED by creating a holding area and beds for this special population of patients.Murphy Medical Center is part of the North Carolina/South Carolina Lean Collaborative. “We continue to move through our lean transformation, so we looked to the tools and techniques used by other industries to plan the remodel in a different way. After some research,we decided to use “2P - Process Preparation” to design the new area”. Designing a new space provided a great opportunity to look at what was being done well and what could be improved.
The plan was to take an existing area that was being used for Cardiac Rehabilitation, and remodel it into a space that would meet the needs of the patient population, the staff, and stay within budget. The team included staff from Nursing, Plant Operations, Environmental Services, Pharmacy, Infection Control, Behavioral Health Coordinator, Customer Service Representative, Provider, ED Manager, an Executive and a Facilitator.
The team was asked to identify and work through the “flows in healthcare”. This was a new way at looking at how the patient, any work and all products flowed through the area and how they were used by the staff. The “flows” used by this team included: the patient, information, supplies, staff, quality, family/visitors, equipment, and outside agencies. Once the team members understood what flowed through the area they worked to define all the processes within the flows. The team next developed at least “7 ways” each of these processes could be completed. This gave them the opportunity to understand the relationship of each flow and weigh them against safety, quality, and efficiency while looking for the most value with the least waste.
The team was then divided into two groups. Each group was given a floor plan of the area to create and present their version of a layout and use of the space. There was much conversation, creativity and negotiation occuring within the groups. The teams learned from each other, then went back to the drawing board with another floor plan. With each iteration, the thought processes and details of the plan improved dramatically. After 7 iterations, the group designs were very similar and a final plan was designed. This plan was used to run simulations within the space.
Using cardboard, tape and other products the team began to build the layout. This gave the team the opportunity to simulate the new processes and workflows and see how they worked within the space. The team tried different scenarios and predicted the results. They found that simulating with cardboard boxes was cheaper and easier than moving complex expensive machines. It was an opportunity to really feel the space and evaluate how everything and everyone would work together. Finally, decisions were made, the action plan was created and the drawing was sent to the architect.
Murphy Medical Center has been using the space for 10 months and has received positive feedback from the staff, the patients, the community and the agencies that come into the space to provide care for the patients. Flow of all ED patients has improved. They have since added telepsyche services. This was anticipated during the design of the area so the space and the wiring was already inplace allowing for an efficient implementation of the service. There have been minimal alterations to the final prodcut. The remodel was completed on time and on budget.
References
1 -Tapemark, Glossary of Terms accessed at on January 8, 2016.