Focus and Leverage Part 181

The Emergency Department improvement team began developing their current state process map and found out very early on that imagining their process and getting it down on paper was not an easy task.  There were disagreements for sure on how the actual process looks, but the most difficult thing was deciding how to map out the five different scenarios that existed within their ED as follows:

Scenario 1:  Patient enters the ED and is moved directly to an ED bed.

Scenario 2:  Patient is triaged (Triage 1), moves to the patient waiting room, patient is triaged (Triage 2), and finally is moved to an ED bed.

Scenario 3:  Patient is triaged (Triage 1), then immediately triaged again (Triage 2), then moves to a waiting room and then is moved to an ED bed.

Scenario 4:  Patient is triaged (Triage 1), then moves to the waiting room, then is triaged again (Triage 2), then moves back to the waiting room, then finally is moved to an ED bed.

Scenario 5:  Patient is triaged (Triage 1), then immediately to Triage 2, then immediately to the ED bed.

The team was struggling on how best to map these individual processes and could not see an easy way to do so.  I asked them a series of questions as follows:

1. Which scenario is the fastest?  The assured me that Scenario 1 was much faster than any of the others.
2. Which scenario is the slowest?  They told me that Scenario 4 was by far and away the slowest.
3. Which scenario is most commonly used for patients and they told me that Scenario 4 was used for about 80% of the patients.

The team asked me what they should do and I simply told them that since Scenario 4 applied to 80 % of the patients that they should focus their efforts on that one since it represents the largest opportunity to improve both the cycle time and patient satisfaction metrics.  This was a classic case of the infamous Pareto Principle meaning that 80% of their improvement will come from 20% of their scenarios (i.e. 1 of 5 scenarios).

I also explained that they should also review what things aren’t done in Scenario 1 that make it much faster than any of the others.  This could in fact become their Ideal State and help them create a future state that meets all of their performance objectives.

The team has completed their first draft of the current state process map and will complete it tomorrow.  They will also be completing their value stream analysis by categorizing each step as value-added (color-coded as Green), non-value-added (color-coded as Red) and non-value-added but necessary (color-coded as Yellow).  When this is completed the team will then create their ideal and future state maps.

One problem the team rightfully pointed out was that it is relatively easy to “speed-up” the front end of the process by reducing the time it takes to get the patient to the ED Exam Room, but getting the doctor to the exam sooner is going to be difficult.  We then created an Interference Diagram (ID) to better understand what gets in the way of reducing the time it takes for the doctor to see the patient.  Figure 1 is the ID the team created.

Figure 1

The team then began looking for potential solutions for each of the interferences listed in the ID which I will report on in my next posting.

Bob Sproull