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Improving Patient Waiting Time at the Emergency Room of Bicol Medical Center, Naga City

Ms. Venus A. Bolivar Mr. Siegfredo L. Lopez Dr. Raymundo B. Ibarrientos Ms. Wilhelmina C. de Castro

E.R.

Bicol Medical Center Emergency Room

22

ER-QI Team Mission

Provide a responsive quality health care system for patients admitted at the Emergency Room of Bicol Medical Center, Naga City

Quality Improvement Team

FMTP Team Medical Svc. : Dr. Raymundo Ibarrientos FMTP Team Finance Svc. : Mrs. Venus A. Bolivar FMTP Team Admin. Svc. : Mr. Siegfredo L. Lopez FMTP Team Nursing Svc. : Mrs. Wilhelmina C. de Castro ER Head : Dr. Elvin Panliboton ER Supervising Nurse : Mrs. Bernadette Betito ER Senior Nurse : Mr. Marlon Clores Chief Resident of Medicine : Dr. Molave Tabanao Admitting Unit : Mrs. Cyril Tolledo Radiology Department : Mr. Marlon Villamora Pharmacy Section : Mrs. Maria Reina Lagramada Social Service Section : Mrs. Agnes Tabios Central Supply Room : Mrs. Marivic Franco Cash Section : Mrs. Ma. Dinia Fortuno Department of Laboratories : Mr. Rexy Alvarez, Mrs. Evangelina Ramos

Quality Improvement Process

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Second level

Third level

Fourth level Fifth level

FMTP Team with Management Click to edit Master text styles Committee Members Second level

Third level

Fourth level Fifth level

FMTP Team with Dr. Edgar O. Esplana, Medical Center Chief

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Step 1: Reason for Improvement

Theme Selection Matrix
Customer Internal External Theme Impact on Need to Total Customer improve Rank

Waiting time of Doctors, nurses, patients at ER lab., x-ray, pharmacy, social service, admitting unit

Patients Relatives Referring agencies

25

Accomplishment BMC management Patients, of job requests and employees Relatives, Other Stakeholders Hospital inpatient days Doctors nurses Records Section, Dietary Service, Billing Unit Doctors Nurses Security Billing Cash Section Patients Relatives

20

16

Absconding of patients Income

Patients Relatives

12

BMC Management Patients,

Them e Waiting time of medical patients admitted at the

Emergency Room of Bicol Medical Center, Naga City

Indicato r
Average waiting time of medical patients admitted at the Emergency Room of Bicol Medical Center, Naga City

Step 2: Current Situation

Average Waiting Time of ER Patients by Department October 2006 N = 40
2.5 2

Ti me

1.5 1 0.5 0

Med

Surg

Pedia

OB
88

ER

Step 2: Current Situation

Emergency Cases by Department Bicol Medical Center, Naga City December 2006

N = 1969
17% patients admitted < 2 hrs
OB Gyne 32% n=640

Surgery 17% n=341

Medical 27 % n=525
Pedia 24% n=463

83 %

patients admitted > 2 hrs

Problem Statement In December 2006, the average waiting time of medical patients
admitted at the Emergency Room was 3 hours and 55 minutes resulting in delayed treatment thereby causing patients dissatisfaction.

Target Indicator
By the end of August 2007, the average waiting time of medical patients admitted at the Emergency Room will be reduced to < 2 hours.

Time: 5 mins
1.

Medical Annex Ward Emergency Room Animated Work Flow

Patient arrives at ER with the companion Triage Nurse classifies patient & issues ER slip
Companion
B. B D.Q D.Q Ped O.B

2.

Patient

2
Triag e

Med ER
Admitti ng

SA

Entrance to

Time: 20mins 3. Admitti ng clerk issues ER record

Medical Annex Ward Emergency Room Animated Work Flow

Companion Patient

4. Nurse monitors/ records vital signs

3
Med ER

Triag e

4 Admitti ng Entrance to

Time: 15 min 5. Physician examines patient & issues initial orders 6

O.R

X-ray

Medical Annex Ward Emergency Room Animated Work Flow

Companion
L a b D.Q B. B Hemo O.B

Patient

Nurse carries out orders 5

Med ER
Admitti ng

D.Q Ped

Triag e
Sur

Cashier

Entrance to

Time: 40 min
6. If patient requires lab exams:

X-ray

Medical Annex Ward Emergency Room Animated Work Flow

Companion brings request to laboratory Lab tech performs exams and issues charge slip Companion pay to Cash Section, get the official receipt, present it to the lab tech & obtain the official result

O.R

6A

Companion
L a b D.Q D.Q Ped Triag e
Sur

B. B Hemo O.B

Patient

Nurse refer results to Physician Med ER

6-A
Cashier

Entrance to

Admitti ng

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Time: 40 min
7. If patient requires radiologic exam:

X-ray

Medical Annex Ward Emergency Room Animated Work Flow

Utility Worker wheel patient to X-ray Dept Rad tech issues charge slip Companion pays to Cash Section, and present official receipt to rad tech

O.R

7-A

Companion

rad tech performs xray exam UW brings back patient with x-ray film to ER Nurse refers x-ray film to Physician

L a b D.Q D.Q Ped

B. B Hemo O.B

Patient

Triag e

7-A
Cashier

Med ER

Sur

Entrance to

Admitti ng

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Time: 25 min
If for admission : 8. Nurse carries out doctors orders
L a b D.Q D.Q Ped B. B Hemo O.B

X-ray

Medical Annex Ward Emergency Room Animated Work Flow

O. R

Companion Patient

8
Med ER
Admitti ng

Triag e
Sur

Cashier

Entrance to

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X-ray

Time: 1 hr, 20 mins

Medical Annex Ward Emergency Room Animated Work Flow

9.

Admitting clerk records admission of patient, informs ward & secures Consent for Admission

O.R

Companion
L a b D.Q D.Q Ped Triag e B. B Hemo O.B

Patient

10. Social Med ER 9 Admitti 10 service ng classifies Entrance to

Sur

Cashier

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Time: 10 mins
11. Nurse checks patients condition and chart 12. UW transports patient to ward

X-ray

Medical Annex Patient admitted, Endorse to ward NOD Ward

O.R

Emergency Room Animated Work Flow

Companion
L a b D.Q D.Q Ped B. B Hemo O.B

Patient

11
Med ER
Admitti ng

Triag e

Cashier

12

Sur

Entrance to

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Emergency Room Work Flow Chart

Patient arrives at the ER Triage Nurse Click to edit Master text styles classifies patients Second level Third level Fourth level Patient needs Fifth level ER care? YES Triage nurse issues ER slip and Admitting Clerk releases ER record 5 min.

No

Refer to OPD or instruct patient to comeback the next day at the OPD

20 min.

A
ER nurse assesses patient and document initial v/s to ER record and refer to ER ROD ER doctor examines patient
NO NO

15 min.

Patient needs diagnostic tests? YE S ER ROD prepares requests for diagnostic procedures

Admit Patient?
YES

B
30 min
Relative brings request to laboratory If for X-ray, IW brings patient to radiology

Lab tech. performs exam Lab. tech issues charge slip

X-ray tech issues charge slip

30 min

40 min

Relative pays to Cash Section

Lab. tech releases results

Relative pays to Cash Section

X-ray tech releases x-ray film

X-ray tech performs exams 40 min

ER nurse refers results to ROD ER nurse refer results to ER ROD

NO Needs confinement? YES

C For Admission
NOD carry out initial orders of ROD NOD informs Admitting Unit of the admission Admitting clerk records admission of patient, secure Consent to Care, and informs ward
Social service classify patients and endorse patients chart to NOD

Disposition of ROD

D For Consultation
NOD carry out initial order of ROD, administer Txt and meds

25 min. NOD issue charge slips and Patients Relative settles bill to cashier

1hr 20 If unable cashier refers min. edit Master text relative to to pay,service who will Click to styles social

NOD checks patients condition and patients chart UW transports patient to ward Admitt ed

decides whether to give discount Second level or to sign a promissory note Third level Fourth Relatives pay at the cashier and level present OR Fifth level to NOD, who then signs patients clearance Pts/ relatives presents clearance to guard
Discharged

10 min.

Step 3: Analysis
Method Manpowe r
In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients dissatisfact ion.

Materials

People / Manpower
In December, 2006, the average waiting Overcrowding of patients time of Patients are not attended immediately medical patients admitted Insufficient trained ER personnel to attend to patientsat the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients dissatisfact ion.

Materials
Patients relatives are asked to buy meds and supplies at the hospital pharmacy / outside hospital Some commonly used medicines and supplies were not available at the ER ER meds and supplies were not replenished promptly In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients dissatisfact ion.

Ineffective Replenishment system

Methods / Processes
In Delay in diagnosis and disposition of ER patient December, 2006, the Delayed released of Diagnostic test results average waiting time of Relatives/ Patients have to undergo circuitiuous process of payment medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients dissatisfact ion.

Methods / Processes
In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients dissatisfact ion.

Delayed in carrying out of ancillary procedures Long queue of ER patients at the ancillary sections Laboratory, Radiology ER patients mixed up with in and out patients

congestion of ER patients Patients were not classified according to severity of cases

No protocol for patient case classification

Step 4: Countermeasures and Practical Methods E F Overall Root Cause Countermeasures Practical Methods
In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients dissatisfaction. Reassignment of senior nurse and clerk to ER

Axn

25

yes

Insufficient trained personnel to attend to ER patients

Ensure adequate number of trained personnel at ER

Detailing of PHO staff as an addtl manpower for ER

no

Hiring of additional ER personnel

no

Step 4: Countermeasures and Practical Methods E F Overall Root Cause Countermeasures Practical Methods
In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients dissatisfaction. Send HC personnel for training in other specialty hospitals

Axn

25

yes

Insufficient trained personnel to attend to ER patients

Capability building of existing ER staff

Conduct specialty training for ER staff

25

yes

Close supervision of ER staff by 5 medical consultants and ER manager

20

no

Step 4: Countermeasures and Practical Methods

Root Cause In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients dissatisfaction. Countermeasures Practical Methods E F Overall Axn

Adopt existing Replenishment system of other 5 tertiary hospital Ineffective replenishment system Ensure an effective replenishment system Review/Revise existing replenishment 5 system

10

no

25

yes

Step 4: Countermeasures and Practical Methods

Root Cause In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients dissatisfaction. Countermeasures Practical Methods E F Overall Axn

Pt/relative have to undergo circuitiuous process of payment

All charges of ER patients for admission should be included in the hospital bill prior to discharge Simplify process of payment ER patients should not be charged of diagnostic tests

25

yes

no

Step 4: Countermeasures and Practical Methods

Root Cause In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients dissatisfaction. Countermeasures Practical Methods E F Overall Axn

Provide area and personnel to attend to ER patients

25

yes

ER patients are mixed up with in and out patients at the different ancillary services

Ensure that ER patients are not mixed with the in and out pts at diff. ancillary services

Provide onestop ancillary services at the ER area

10

no

Step 4: Countermeasures and Practical Methods

Root Cause In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients dissatisfaction. Countermeasures Practical Methods E F Overall Axn

Develop procedures for 5 ER patient case classification

25

yes

No protocol for patient case classification

Formulate protocol for patient case classification Adopt patient case classification from other hospitals

no

Action Plan
Countermeasures: Assign additional personnel to attend to ER patients
Practical Method Tasks

Who Does
nChief

Start Date April 24, 2007

Date Done April 24, 2007

Reassignment nConduct Meeting with the of senior nurse Nursing Service and clerk to ER Management Team and Medical Records Section
nAssign

Nurse nChief AO nMedical Center Chief nER QI Team

senior nurse per shift as a triage nurse and as a "bed site manager

May 1, 2007

May 1, 2007

Assign job order clerk to list patients for consultation at the triage area
n

May 1, 2007

May 1, 2007

Action Plan
Countermeasures: Assign additional personnel to attend to ER patients
Practical Method Send healthcare personnel for training in other specialty hospitals

Tasks Determine training needs of ER personnel

n nCoordinate

Who Does
nTraining

Start Date May 4, 2007

Date Done May 14, 2007

with other agencies regarding training programs

nSchedule

Office nER Head nER doctors and nurses nER QI Team

May 15, 2007

May 31, 2007

training program of ER personnel

June, 2007

August, 2007

Action Plan
Countermeasures: Conduct special training for ER personnel
Practical Method

Tasks

Who Does

Start Date
qSeptember

Date Done
qSeptember

nTraining Office Conduct nDevelop Specialty specialty training program for nurses nER Head for ER staff nER doctors and nTrain staff nurses for nurses the specialty program. nER QI Team nAccept volunteer nurses for the specialty program nMonitor implementation of program nEvaluate effectiveness of the implementation of the program

4, 2006 qOct. 30, 2006 qSeptember 25, 2006

qOctober,

18, 2006 qOngoing

qOngoing

2006

qMonthly

Action Plan
Countermeasures: Ensure an effective replenishment system
Practical Method Review / revise existing replenishme nt system
nConduct

Tasks

Who Does

Start Date April 25, 2007 May 7, 2007 May 8, 2007 May 15, 2007

Date Done April 25, 2007 May 7, 2007 May 10, 2007 August, 2007

Meeting with the n ER QI pharmacy, CSR and the ER staff Team to review/ revise existing replenishment system nER QI n Present reviewed and revised Team replenishment system to MANCOM for approval nCAO n Issuance of hospital order to implement revised replenishment system nMonitor and evaluate nER QI effectiveness of the Team replenishment system

Action Plan
Countermeasures: Simplify process of payment
Practical Method All charges of ER patients for admission should be included in the hospital bill prior to discharge
q

Tasks Review / Revise of policy requiring payment before issuance of result qPresent to MANCOM for approval of revised policy qIssuance of hospital order to revise the policy qMonitor/ evaluate effectiveness of the replenishment system

Who Does ER QI Team

n

Start Date May 7, 2007 May 21, 2007

Date Done May 21, 2007 May 21, 2007 May 28, 2007 August, 2007

nER

QI Team

nCAO nER

May 28, 2007 May 29, 2007

QI Team

Action Plan
Countermeasures: Prioritize ER patients at the different ancillary services
Practical Method Tasks Who Does
nChief

Start Date April 24, 2007

Date Done April 24, 2007

Provide area nConduct Meeting with and personnel the different ancillary to attend to ER services to provide an patients area and personnel to attend to ER patients Provision of separate window/ area for ER patients
n nAssign

Nurse nChief AO nMedical Center Chief nER QI Team

May 1, 2007

May 1, 2007

personnel to attend to ER patients

May 1, 2007

May 1, 2007

Action Plan
Countermeasures: Observe protocol for patient case classification
Practical Method Develop procedures for ER patient case classification
nConduct

Tasks Meeting with the medical and nursing service to formulate patient case classification nPresent to MANCOM for approval of patient case classification
nIssuance

Who Does
nCMPS nDepartmen

Start Date May 7, 2007

Date Done May 7, 2007

of hospital order to implement patient case classification

nMonitor

t Head nChief Nurse nNurse Supervisor nSenior Nurse

nER

May 28, 2007 May 29, 2007 June4, 2007

May 28, 2007 May 31, 2007 August 30, 2007

QI Team nCAO
nER

effectiveness of implementation

QI

The Canadian Triage and Acuity Scale ( CTAS)

The CTAS was designed to help ensure that patients who need immediate care get seen first. The CTAS system group patients into 5 categories. CTAS I Resuscitation - immediately CTAS II CTAS III CTAS IV CTAS V Emergent Urgent - within 15minutes - within 30 minutes -within 120 minutes

Less Urgent - within 60 minutes Non-urgent

The CTAS classified under I-III were the only patients included in the study since CTAS IV V were under observation.

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Step 5: Result
Waiting time of medical patients admitted at the Emergency Room before and after the quality improvement project Before QI (n=525) After QI (n=235)

83% 17%

23% 77%

December1-31, 2006

August 10 to September 7, 2007

4242

patients admitted > 2 hrs patients admitted < 2 hrs

Emergency Room Slip

Name of Patient: __________________Age: ______ CTAS :______ Chief Complain : __________________Date: Time Arrived : For X-Ray: Time Requested: _______ Time left the ER : ______ Time left the X-ray: ___ For Laboratory : Time Requested : _______Time Req. forwarded:_ Time specimen was taken: Time Admitted by ROD: __________ Time Top sheet was obtain: _______Time classified by social service: Time wheeled to ward: ___________Time endorsed by ER NOD to ward NOD: Time seen by ward NOD: ______________________________ Time result was released: _ _____ __Time seen NOD :_______Time seen ROD:_______

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Step 6: Standardization

To ensure sustainability of the Revised Emergency Room Workflow :

1.

Utilization of ER slip to continuously monitor the patients waiting time. Utilization of the CTAS as basis for the patient case classification. Regular conduct of the Specialty training program.

1.

1.

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Revised Emergency Room Work

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Revised Emergency Room Work Flow

STEP 1: Initial Triaging of Patient Nurse II Triage Nurse 5 minutes
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Revised Emergency Room Work Flow

STEP 2: Issuance of ER Record / ER Slip ER clerk 10 minutes
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Revised Emergency Room Work Flow STEP 3: Initial assessment of Patient Nurse assigned on Medicine ER 10 minutes

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Revised Emergency Room Work Flow STEP 4: Physicians Initial Assessment Confirm CTAS Classification of Patient ER Medical Resident 10 minutes

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Revised Emergency Room Work Flow STEP 5: If for diagnostic work up Perform laboratory examination Perform radiological examination Med. Tech on duty / X ray tech on duty 5050 30 minutes

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Revised Emergency Room Work Flow STEP 6: If for admission, Med ROD issues admitting orders Med NOD carries out initial doctors orders. Resident On Duty/ Nurse On Duty 5151 10 minutes 10 minutes

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Revised Emergency Room Work Flow STEP 7: Issuance of Top sheet Admitting clerk 10 minutes

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Revised Emergency Room Work Flow STEP 8: Classifies patients Social Worker 5 minutes

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Revised Emergency Room Work Flow STEP 9: Wheel patient to ward Utility worker 10 minutes

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Revised Emergency Room Work Flow STEP 10: Endorse patient to ward ER Nurse on duty 5 minutes

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Step 7: Future Plans

Issue hospital order for the institutionalization of the revised workflow for medical patients at the ER. Issue hospital order to institutionalize the new Replenishment system. Issue hospital order for the full implementation of the simplified payment process. Conduct similar studies in other ER clinical departments Formulate and institutionalize a Manual of Operations for Emergency Case Management for the Bicol Medical Center.
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1.

1.

1.

1.

1.

Step 7: Future Plans

6.

Systematize Records Management by separating new and old patients thereby facilitating issuance of ER Records. Post signages of revised ER workflow on strategic places. Reactivate the Satellite Laboratory Room for chemistry examinations at the Out Patients Department Put up a Satellite X-ray Room adjacent to the ER.
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7.

7.

7.

If we bond together and support each other.. If we make true the spirit of teamwork.. Regardless of our differences, we can rise to meet our challenges. If we understand the real value of CARING If we are aware of the feeling of SHARING.. LIFE WILL BE EASIER AND THE PASSING OF YEARS MORE FULFILLING ..
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Dios Mabalos po.

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