Kings County Hospital Center in Brooklyn, a member of the New York City Health and Hospitals Corporation, was recognized nationally for using Toyota Lean methodologies to transform its ED, improve efficiency and patient flow and shorten the time it takes for a patient to see a physician.
A Kings County team described the improvement process in an article published in a recent issue of the peer-reviewed Journal for Healthcare Quality, which recognizes innovative and evidence-based care efforts at a select number of safety net hospitals across the country.
The journal article, “A Structured Approach to Transforming a Large Public Hospital Emergency Department via Lean Methodologies,” describes a number of successful initiatives adopted by emergency medicine professionals at Kings County to eliminate waste, enhance safety and improve efficiency through the Lean method, known as Breakthrough at HHC, during an 18-month period starting in October 2009.
Although the median number of ED patient visits rose 7.3% during that period, from 10,867 patients a month to 11,661 a month, the total time a patient spent in the ED was reduced by 36 minutes. The amount of time it took for a patient to be triaged was cut in half, to a median of 18 minutes, and the amount of time it took to see a physician was reduced by 30 minutes.
“HHC has been applying the Breakthrough process in New York City public hospitals since 2007, making quality, efficiency and financial improvement an ongoing and permanent process throughout our system,” HHC President Alan D. Aviles said in a news release. “Kings County has done an excellent job in using Breakthrough tools to increase efficiency, eliminate waste and improve the patient and staff experience.”
Aviles sentiments are echoed by Kings County Hospital management staff. “There have been more than 30 events related to Lean/Breakthrough [that]have synergistically worked to improve efficiency, safety and satisfaction,” said Glenda Martin-Grant, RN, MSN, ANP, GNP, assistant director of nursing for the department of emergency medicine at KCHC. “We now see patients in less time, complete their care more rapidly and have implemented numerous safety initiatives, including improved use of bundles, quicker ordering of important tests and better follow-up of patients. In addition, the integration of new technology such as whiteboards and dashboards — done through the Lean/Breakthrough process — has allowed us to better gather and understand information related to the flow and treatment.”
Kings County has employed Lean in various areas and departments since late 2008. In the ED, the Kings County team conducted Rapid Improvement Events, a key Breakthrough tool used to identify waste, design new processes and effect immediate change. The team reviewed how patients were being processed in the ED, identified waste and redundancy that could be removed to make the process more patient-centered, put the new processes in place and evaluated the results to ensure sustainment.
“One of our best practices in the use of Lean was to develop and roll out a hospital-wide initiative to respond to emergency department overcrowding,” Martin-Grant said. “Multiple disciplines and administration were involved in the planning and implementation of this accomplishment and we have seen real improvement in our times to beds, decompression of the ED and the critical buy-in from the entire institution.”
As with any new system, getting the staff to the point where they were comfortable with the changes required a learning curve, Martin-Grant said. “[Although] people were comfortable with the idea, the concept of Lean was new and they needed to integrate their current practice with new ideas and vision,” she said. “While there was overall acceptance, once the early initiatives took hold and the nurses saw firsthand the benefits, the acceptance was wider and stronger. As the nurses found they were directly involved in planning and implementing the changes and improvements, the buy-in of the process increased tremendously.”
An adjunct professor for the accelerated BSN program at SUNY Downstate College of Nursing in Brooklyn, Martin-Grant said she incorporated Breakthrough in her students clinical experience.
“They are able to observe hand-off by the nursing staff, which influences standard work that positively impacts patient care,” she said.
Kings County was among four U.S. public hospitals recognized March 15 by the National Association for Public Hospitals and Health Systems and the National Association for Healthcare Quality in Washington, D.C., for programs that demonstrate that effective quality improvement measures adopted by safety net hospitals can help address disparities to improve overall patient care and achieve high standards of quality.
Regional reporter Tracey Boyd contributed to this story.