Docimo A B, Pronovost P J, Davis R O, Concordia E B, Gabrish C M, Adessa M S, Bessman E
Johns Hopkins Medicine, Baltimore, MD, USA.
Jt Comm J Qual Improv. 2000 Sep;26(9):503-14. doi: 10.1016/s1070-3241(00)26042-2.
In 1998 the emergency department (ED) Work Group at Johns Hopkins Bayview Medical Center (Baltimore) worked to reinvigorate the fast-track program within the ED to improve throughput for patients with minor illnesses and injuries who present for care. There had been two prior unsuccessful attempts to overhaul the fast-track process.
The work group used a change model intended to improve both processes and relationships for complex organizational problems that span departments and functional units. Before the first work group meeting, the work group evaluated the institutional commitment to address the issue. The next step was to find data to fully understand the issues and establish a baseline for evaluating improvements--for example, patients with minor illnesses and injuries had excessively long total ED (registration to discharge) times: 5 hours 57 minutes on average for nonacute patients. ONLINE AND OFFLINE MEETINGS: The work group identified process problems, but relationship barriers became evident as the new processes were discussed. Yet offline work was needed to minimize the potential for online surprises. The work group leaders met separately in small groups with nursing staff, lab staff, x-ray staff, registrars, and physician's assistants to inform them of data, obtain input about process changes, and address any potential concerns. The group conducted four tests of change (using Plan-Do-Study-Act cycles) to eliminate the root causes of slow turnaround identified previously.
Total ED time decreased to an average of 1 hour 47 minutes; the practice of placing nonacute patients in fast track before all higher-acuity patients were seen gained acceptance. The percentage of higher-acuity patients sent to fast track decreased from 17% of all patients seen in fast track in January 1998 to 8.5% by February 1999. Patients with minor illnesses and injuries no longer had to wait behind higher-acuity patients just to be registered. The average wait for registration decreased from 42 minutes in January 1998 to 14 minutes in February 1999. Physician's assistant, nursing, and technician staff all report improved working relationships and feeling a team spirit.
The offline component of the integrated model helped to improve organizational relationships and dialogue among team members, thereby facilitating the effectiveness of online efforts to improve processes. This model has also been applied to improve patient registration (revenue recovery) and the emergency transfer and admissions process.
1998年，约翰霍普金斯湾景医疗中心（巴尔的摩）的急诊科工作组努力重振急诊科内的快速通道项目，以提高前来就诊的轻症和轻伤患者的就诊效率。此前曾有两次全面改革快速通道流程的尝试均未成功。
该工作组采用了一种变革模型，旨在改善跨部门和职能单位的复杂组织问题的流程和关系。在第一次工作组会议之前，工作组评估了机构解决该问题的决心。下一步是寻找数据以充分了解问题并建立评估改进的基线——例如，轻症和轻伤患者的急诊科总时长（从挂号到出院）过长：非急症患者平均为5小时57分钟。线上和线下会议：工作组确定了流程问题，但在讨论新流程时，关系障碍变得明显。然而，需要进行线下工作以尽量减少线上意外情况的可能性。工作小组组长分别与护理人员、实验室工作人员、X光工作人员、挂号员和医师助理进行小组会面，向他们通报数据，获取有关流程变更的意见，并解决任何潜在问题。该小组进行了四次变革测试（使用计划-执行-研究-行动循环），以消除先前确定的周转缓慢的根本原因。
急诊科总时长降至平均1小时47分钟；在所有病情较重的患者就诊之前先将非急症患者安排在快速通道的做法得到了认可。被送往快速通道的病情较重患者的比例从1998年1月快速通道所有就诊患者的17%降至1999年2月的8.5%。轻症和轻伤患者不再需要在病情较重的患者后面排队等候挂号。平均挂号等待时间从1998年1月的42分钟降至1999年2月的14分钟。医师助理、护理人员和技术人员都报告称工作关系得到改善，并感受到了团队精神。
综合模型的线下部分有助于改善组织关系和团队成员之间的对话，从而促进线上改进流程努力的有效性。该模型还被应用于改善患者挂号（收入回收）以及紧急转诊和入院流程。
