FOUCS - PDCA

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EFFECTS OF IMPLEMENTATION OF FOCUS-PDCA MODEL TO DECREASE

PATIENTS’ LENGTH OF STAY IN EMERGENCY DEPARTMENT Mohammed Alshahrani

1 and Amal Alsulaibaikh

2

Consultant of Emergency and critical Medicine, College of medicine, University of Dammam.

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ABSTRACT

Introduction: Boarding patients in emergency department (ED) is a universal problem in all

health care sectors, facilitating patients flow in and out of the emergency department is an important

step to improve patients and staff satisfaction and even patients outcome. Objectives: To study the

effect of implementing one of the quality improvement methods, the FOCUS-PDCA in decreasing

patients length of stay in the ED. Methods: Multidisciplinary team was formed and the process of

finding opportunity, organizing team, Clarify the process, understand the process and select the desired

outcome followed by (Plan-Do-Check-Act ) process over six months period at the Emergency

department of a university hospital setting. A consensus-based approach was performed to identify

areas of improvement with time limits and responsible assigned personal. Results: After

implementation of the above suggestions for the period of 6 months, the data was collected to study the

rate of ER overstay. Overall, the rate of ER overstay was reduced from 9.81/1000 to 6.92 per 1000

patients, demonstrating a 29.5% decrease [Figure 1]. This performance improvement project was

achieved significant improvement (P =0.030).Conclusion: FOCUS-PDCA quality improvement

method was effective in reducing emergency department patients’ length of stay.

INTRODUCTION

Emergency department (ED) crowding has been

described as the most serious problem that

endangers the reliability of health care system

worldwide [1]

It has been reported to cause delays in

diagnosis, delays in treatment, decreased quality

of care, and poor patient outcomes. [2,3]

According to the Joint Commission on

Accreditation of Healthcare Organizations

(JCAHO), over one half of all “sentinel event”

cases of morbidity and mortality secondary to

delays in treatment occur in hospital EDs, and

ED overcrowding has been cited as a

contributing factor in 31% of these cases. [4]

The true causes of ED overcrowding are much

more complex,[ 3,5]

and include, inadequate

inpatient bed capacity, higher severity of

illness, and hospital system restructuring.

Hospital bed shortages have been studied as

factors that potentially affect crowding. Non

availability of ED beds because they are

occupied by admitted patients waiting for

transfer from the ED to inpatient units restrict

the EDs capacity to accept new arrivals and

consume EDs resources [6-7].

Because the main causes of ED overcrowding

seem to originate outside the ED, the only way

to truly alleviate ED overcrowding is to focus

our attention on system-wide reform. In this

project, we used FOCUS-PDCA methodology

looking for improvement process. The (PDCA)

method was presented first time by a quality

expert Dr. Edwards Deming in 1950's. 8

This process helps in identifying and solving

problems and also applicable for the continuous

quality improvement of various clinical

aspects. 9

The FOCUS-PDCA is an improvement

methodology that many organizations use to

guide their improvement efforts. It’s simply a

formalized process for improvement and we

aimed here to achieve shortening the ED length

of stay of our patients by applying this

methodology.

METHODS

Study Settings

This study was conducted at King Fahd Hospital

of the university, University of Dammam, Saudi

Arabia during the process of attaining Joint

Commission International accreditation during

the period from Jan to June 2015. As a measure

to improve the quality emergency services, one

critical issue consists of overcrowding in

Emergency department. From the KPI annual

report 2014, researchers found that the rate of

patients who stay longer than 6 hours in the ER

was 9.2 /1000 patients, where six hours is the

internal target. Accordingly, the researcher

decided to use FOCUS-PDCA Model with an

objective to reduce the ER overstay. The study

was conducted for the duration of 6 months and

necessary process redesign was carried during

this period for obtaining optimal results.

Statistical analysis

Data’s were presented by mean with standard

deviation. Control charts were used to measure

the variation of the process. Performance

improvement after implementation of the

project was tested by using independent sample

t-test. All the analysis were performed using

MINITAB version 17. P value less than 0.05

was considered to be significant.

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RESULTS

FOCUS-PDCA

The quality improvement methodological

framework adopted in this study is based on

FOCUS-PDCA Model. The Quality tools and

techniques and the strategies adopted in each

phase of FOCUS-PDCA to optimize the ER

overstay is described below:

Find an opportunity The rate of ER overstay 9.2 per 1000 patients as

per the key performance report of 2014, it was

inferred that there is need to reduce the ER

overstay, which had been identified as one of

the critical factor contributing to dissatisfaction

among ER patients.

Organize a team

To accomplish this project, a special team was

formulated and its consisted of Team leader (ER

consultant ), Laboratory representative,

Radiology Superintendent, Nursing quality

officer, there are 2 IT specialty, 1 special ER

nurse and a supporting staff from the Quality

office of the hospital. The primary objective of

the team is to improve and optimize the ER

overstay.

Clarify the process

This phase involves documentation and

evaluation of the existing systems in various

processes of ER services. The team members

was explored all the issues related with ER stay

process and its described below, it was carried

out using process flow chart to analyze all the

staps starting from the arrival of patients in ER

and continued with sequential activities until the

patients stay more than 6 hours in ER

.

Understand the process

In order to find out the reasons for the delay in each of the sub processes of the ER overstay, a root

cause analysis was carried out and it is depicted below:

Significant causes for ER overstay were depicted below (Figure 1), its indicate that most of them were

due medical re-evaluation.

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Select a desired outcome

To decrease 20% from the rate of patient who are staying in Emergency Department more than 6 hours

by the end of august 2015.

Plan

A plan for optimal solution of ER overstay was made and circulated to all responsible persons to

ensure the improved process [Table 1]

Table 1: The process plan to sustain and control the process for long run Item Action Plan

Transportation for ER STAT samples to laboratory

• Re-educate porters regarding STAT samples • Have a STAT lab in the ER • To increase no. of porters

Medical re-evaluation: Junior doctors are seeing the patients then the

seniors: They are hesitate to call the consultants

• To send consultancy policy to all department heads to be aware about it.

• Monitor the process of consultation • Validity the data accuracy

Bed availability /ICU bed not available/ non-eligibility Whenever the bed is not available, inform medical director to find a

bed even in another ward or service.

DO

In this phase, after formation the action plan the team members were implemented the following things

along with optimal plan.

• Continuous education to all ER staffs • Reasons for Overstay should be discussed frequently during the Unit Staff Meeting, Administration

Meeting and performance improvement opportunities be explored and shared through the ER units.

• Complete the issue on the action plan that is assigned to each member Check the Improvement (Analysis of the data)

After implementation of the above suggestions for the period of 6 months, the data was collected to

study the rate of ER overstay. Overall, the rate of ER overstay was reduced from 9.81/1000 to 6.92 per

1000 patients, demonstrating a 29.5% decrease [Figure 1]. This performance improvement project was

achieved significant improvement (P =0.030) [Table 2]

Figure 1: Effectiveness of FOCUS-PDCA model

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Table 2: Independent t-test for testing the Project improvement

Time period N Mean S,D Mean diff. P value

Before PI 9 9.81 2.07

2.89

0.030 After PI 6 6.92 2.24

Act

The improvement strategies were adopted in the plan will be continued until getting the most feasible

solution. In addition, the team members were updated by the process owners on a monthly basis

through data tracking and also for getting optimal of solution for ER overstay the following things

should be adopted:

• Transparent bed management through proper Bed Management systems • Use a protocol for common conditions. • Focus on efficient use of the available bed particularly through admission and discharge planning.

DISCUSSION

FOCUS-PDCA is easy to learn quickly, and

with time It keeps everyone focused on the

improvement effort. The structure of the process

encourages focus and accountability for

completing assigned tasks. It gets employees

(and volunteers) involved in the process of

problem solving. This improvement model

places value on the wisdom and experience of

front-line workers (employees or volunteers)

and encourages the use of their expertise. It

provides a plan and steps for improvements.

These plans help to eliminate the frustrations

that come with working in an environment that

allows organizational problems to dictate

internal processes, instead of the opposite. In

this quality improvement project we prove that

the FOCUS-PDCA method shortened the

overstaying time in the emergency department

and improved over all patients flow and

satisfactions. Such improvement usually its

reflected on patients outcome. Studies have

shown that delayed admission especially in

critically ill patients in emergency department

worsen their outcome, Chalfin and his group

found that critically ill emergency department

patients stays in ER more than 6-hr delay before

being transferred to ICU had more length of

hospital of stay and mortality also. 10

his suggests

the need to identify factors associated with

delayed transfer as well as specific determinants

of adverse outcomes. FOCUS-PDCA was used

in many improvement projects in clinical

practice, Oyvind and colleagues proved that the

FOCU-PDCA made Change and improvement

in health care achievable despite limited

financial resources. 11

Also in critical care

practice using the FOCUS-PDCA found to

reduce severe pain and stress-related events

while moving ICU-patients which is associated

with a decrease of serious adverse events on

those group of patients. 12

CONCLUSION

Based on the results of this study, it seems that

FOCUS-PDCA is an effective quality

improvement method that helped in decreasing

overstaying in ED which is a vey challenging

problem in clinical practice.

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