Meritus Health ED Redesign – Direct Bedding

Starting in the spring of 2016, the Meritus Health Emergency Department team began using a combination of 3P and daily improvement cycles (Toyota Kata) to take what it learned from Lehigh Valley Health Network's direct bedding model to redesign their patient flow. Special thanks to Lehigh Valley's Chris Kita, and Dr. Rick Mackenzie for hosting the Meritus ED team at your site!

Steps and associated tools:

  1. Map perfect flow for one patient
  2. Add volume
  3. Add barriers

1.  Map Perfect Flow (for one): 

After determining the scope and goals (ESI 2-5's, eliminate patient wait times prior to assessment by Physician and Nurse, vertical patients will be kept vertical), we mapped the overall flow: 

Direct Bedding Flow 1

Then we mapped out the three value streams, choosing the most complicated patient type that would require the most resources (chest pain/shortness of breath). After mapping out the three value streams, we tested other patient types to verify the process sequence. For example, a long bone fracture would follow the same sequence, but skip the EKG step, etc. From top to bottom: 

  1. Chest Pain, not vertical (patient requires a stretcher or bed)
  2. Chest Pain, vertical
  3. Procedures

Direct Bedding Value Streams

2. Add Volume

For this step, we calculated a fairly heavy day (ranked about top 20% heaviest day for the year in terms of volume). This would allow us to determine how many people would have to flow through the Rapid Assessment Zone (RAZ):

 Direct Bedding - Volume

3. Add Barriers

Finally, we conducted tabletop simulations and a "process-at-a-glance."

Direct Bedding Tabletop simulation 1 Process at a glance post it

Process at a Glance (click image for Excel file created by Joshua Kenney):

Direct Bedding - Process at a Glance png

Finally, it was time to go-live. ED leadership created a standard work sheet on a flip chart to help introduce the concept at the morning huddle and for use as a reference throughout the day. 

Direct Bedding Pilot SW 2016.05.05

Throughout the day, obstacles were logged on additional flip-chart pages. If resolved through rapid-experiments throughout the day, they were crossed off of the list. The pilot lasted until mid-afternoon with plenty of learning for the debrief the following week. The biggest lesson learned is the visibility the process gives the ED team to the volume throughout the day and what resources will be required to stay ahead of it. As we observed during our trip to Lehigh Valley, bringing in a second provider at 11 am had already put us at a deficit. In order to get ahead of the volume, we predict scheduling the second provider to arrive two hours earlier will alleviate the burden. 

Feel free to provide us any suggestions or feedback! 

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