Allaudeen Nazima, Vashi Anita, Breckenridge Julia S, Haji-Sheikhi Farnoosh, Wagner Sarah, Posley Keith A, Asch Steven M
Department of Medicine (Drs Allaudeen and Posley), Center for Innovation to Implementation (Drs Vashi and Asch), Office of Quality, Safety & Value (Dr Breckenridge), and Department of Nursing (Ms Wagner), Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and Department of Medicine, Stanford University School of Medicine, Stanford, California (Drs Allaudeen, Posley, and Asch and Ms Haji-Sheikhi).
Qual Manag Health Care. 2017 Apr/Jun;26(2):91-96. doi: 10.1097/QMH.0000000000000132.
The practice of boarding admitted patients in the emergency department (ED) carries negative operational, clinical, and patient satisfaction consequences. Lean tools have been used to improve ED workflow. Interventions focused on reducing ED length of stay (LOS) for admitted patients are less explored.
To evaluate a Lean-based initiative to reduce ED LOS for medicine admissions.
DESIGN, SETTING, PATIENTS: Prospective quality improvement initiative performed at a single university-affiliated Department of Veterans Affairs (VA) medical center from February 2013 to February 2016.
We performed a Lean-based multidisciplinary initiative beginning with a rapid process improvement workshop to evaluate current processes, identify root causes of delays, and develop countermeasures. Frontline staff developed standard work for each phase of the ED stay. Units developed a daily management system to reinforce, evaluate, and refine standard work.
The primary outcome was the change in ED LOS for medicine admissions pre- and postintervention. ED LOS at the intervention site was compared with other similar VA facilities as controls over the same time period using a difference-in-differences approach.
ED LOS for medicine admissions reduced 26.4%, from 8.7 to 6.4 hours. Difference-in-differences analysis showed that ED LOS for combined medicine and surgical admissions decreased from 6.7 to 6.0 hours (-0.7 hours, P = .003) at the intervention site compared with no change (5.6 hours, P = .2) at the control sites.
We utilized Lean management to significantly reduce ED LOS for medicine admissions. Specifically, the development and management of standard work were key to sustaining these results.
将已收治患者安置在急诊科会对运营、临床及患者满意度产生负面影响。精益工具已被用于改善急诊科工作流程。针对缩短已收治患者在急诊科停留时间（LOS）的干预措施较少受到探索。
评估一项基于精益理念的举措，以缩短内科住院患者在急诊科的停留时间。
设计、地点、患者：2013年2月至2016年2月在一所大学附属退伍军人事务部（VA）医疗中心进行的前瞻性质量改进举措。
我们开展了一项基于精益理念的多学科举措，首先举办快速流程改进研讨会，以评估当前流程、确定延误的根本原因并制定对策。一线工作人员为急诊科停留的每个阶段制定了标准工作流程。各科室建立了日常管理系统，以强化、评估和完善标准工作流程。
主要结果是干预前后内科住院患者在急诊科停留时间的变化。采用差异分析方法，将干预地点的急诊科停留时间与同期作为对照的其他类似VA设施进行比较。
内科住院患者的急诊科停留时间减少了26.4%，从8.7小时降至6.4小时。差异分析表明，与对照地点无变化（5.6小时，P = 0.2）相比，干预地点内科和外科住院患者的急诊科停留时间从6.7小时降至6.0小时（-0.7小时，P = 0.003）。
我们利用精益管理显著缩短了内科住院患者在急诊科的停留时间。具体而言，标准工作流程的制定和管理是维持这些成果的关键。
