Abstract Text:

Safely and efficiently moving patients through the admission process is a key concern for emergency and hospital medicine faculty. Our hospitalist group admits approximately 400 patients per month, each admitting physician evaluates approximately 7.5 patients per  shift, utilizing individual approaches. We aimed to improve the quality of our admissions by  standardizing our admissions process by utilizing Lean/Six Sigma (LSσ) methodology. LSσ was developed in the automotive manufacturing industry and is increasingly being applied to quality improvement in the healthcare setting.  A basic tenet of LSσ is that  standardized processes are more efficient and less prone to error when completed from start to finish without interruption, termed “one-piece-flow” (OPF). As contrasted with performing individual parts of a process in groups, termed “batching.” Many admitting  physicians tend to “batch” admissions, seeing two or three patients sequentially, followed by order entry for those patients, then documentation, all performed in “batch” processing.

To standardize and improve the admission process by implementing a “one-piece-flow” technique for patient admissions.  

Select hospitalist providers committed to performing all patient admissions in OPF, whereby an admitter focused on one patient from initiation of chart review through exam, order entry and documentation, without interruption.  Pages and other distractions were addressed only at the completion of this process, unless emergent.  To assess the impact of this process on efficiency, we analyzed  the time page was received from ER, time to call back to ER, time at initiation of chart review, time of evaluation of patient, time orders were placed, time of H&P completion, and time of sign-out note completed, before and after implementation of OPF. The  times were reported on log sheets completed by attending physicians as admissions were performed. Our pre-intervention data was collected from 11/14/15 – 12/14/15. Our post intervention period data was collected at 30 days, 90 days and 6 months. We reviewed  pre and post data encompassing 95 log sheets obtained over 60 days reflecting different eight different providers, averaging 7.5 patients per shift. We then had a second endpoint at 90 days and analyzed 45 log sheets, reflecting 4 different providers.  

We found a substantial reduction in time of the admission process  across all time points. Compared with pre-implementation, at 30 days there was a decrease in time of 30 minutes from time page was received from the ER to time of sign-out note completion: from 2hrs 18min to 1hr 48min. In comparing time page received from  ER to time orders are placed for the patient, OPF admitting reduced time by 1hr: from 2hrs 40min to 1hr 40min. And when comparing initiation of chart review to sign-out note completion, OPF achieved a reduction in time of 57min: from 1hr 27min  to 30 min. The 90 and 180 day sustainment data showed a consistent decrease of 57 min over the entire admission process using OPF, from 2hr 18 min to 1hr 31min.

An OPF method applied to admissions was associated with a sustained and clinically meaningful decrease in time for the admission process.  These results may have significant implications for hospitals seeking to improve the efficiency of their admission processes.  Further study is needed to examine whether OPF techniques also result in fewer errors during the admissions process.