Patient-Centered Care in KCCF Triage
On the morning of November 18, a team of nurses, medical providers (doctors and nurse practitioners), and corrections officers met in a King County Correctional Facility (KCCF) conference room to see if they could rapidly design and pilot test a new way to triage patients.
Prior to this meeting, nurses and providers were at opposite ends of the triage process, sending notes on patients to each other through the computer system.
Nurses performed the triage exam alone, checking patients with medical concerns in order to assess illnesses and wounds. Following the exam, nurses would log patient information into the system in what they call “reminders” (because these pop-up on the medical provider’s computer as a reminder that the patient requires provider action).
Providers would then review the exam notes and decide on treatments or to schedule follow up face-to-face appointments for those patients.
Because this process relied so heavily on passing information via reminders, providers often had difficulty keeping up and, at times, would have to work overtime just to review the reminders!
More importantly from the patient’s point of view, the reminder-intensive process meant that many patients waited, sometimes for days, to receive a definitive diagnosis and treatment. At times, an inmate-patient would be released from the jail before he or she could get a diagnosis or receive treatment.
If I Were The Patient…
“If I were the patient,” asks Jail Health Services Medical Director Ben Sanders, “would I want to wait for definitive healthcare?”
That customer-focused question drove the entire pilot. The pilot was designed to provide definitive care to patients more quickly, reducing patient wait times for answers and treatments. The nurses, medical providers, and corrections staff wanted to change their process so that the vast majority of patients would have a diagnosis and treatment plan within minutes rather than days.
By mapping the current state and the future state, the team identified and rearranged the essential tasks of the old process while eliminating the wasteful pieces of it. With representatives from every facet of the work in the room, in just a few hours, the team mapped a way to do the work more effectively and quickly, with providers and nurses working triage side-by-side, handing off patients in real time.
And they wanted to implement a rapid PDCA cycle to test their plan immediately.
That afternoon, the whole team walked through the new process in the triage rooms to see how well their plan could actually work and what needed to be changed.
Turning the conference room brainstorming into “try-storming” in the triage rooms the team was able to unearth some challenges that hadn’t been fully explored in the conference room. Some of these included:
– What medical supplies would providers need and how could those be stocked in the small triage rooms?
– How would patients be prioritized and moved between nurses and providers?
– How the inmate-patients would be brought out of cells and where they would sit in order to maintain security but also protect their patient privacy?
Rapid cycles of experimenting with new ways to do the work—testing ideas for possible improvements and making adjustments on the fly—are central to Lean continuous improvement.
These rapid cycles of change can lead to remarkable changes in how the work is done and significant outcome improvements in a short time, even in the face of the institutional barriers and organizations silos that often stymie improvement-by-committee efforts.
This Patient-Centered Care pilot is a King County case in point.
In just six days, a seven-person team of employees from two different government departments, working in a highly structured environment (King County Correctional Facility) reorganized an intensive work process—patient triage—to be more customer oriented, developed a plan to measure the results of their overhaul, and implemented the plan.
Staff from these two agencies, Jail Health Services (JHS) and Department of Adult and Juvenile Detention (DAJD), did almost all of the initial planning in a single day.
Two short weeks later, the team had completed the pilot, gathered and reviewed data on its success, and made recommendations to senior leadership for a full implementation of the new triage approach.
On January 15, 2015, only two months after the pilot planning began, the old triage process was gone and the new process was fully in place for all staff.
To know whether or not the pilot was successful, it was important for the team to define what they were trying to achieve. The team developed a measurement plan, detailing what metrics they wanted to track and how they would track them. These would be reviewed at the end of the pilot to determine if their work had been successful or if the process needed to be reviewed.
Lean Specialist Greg Burnworth emphasized the importance of tracking the impact of the experiment, “Rather than just rush to implement things blindly,” he explains, ”we were going to test and measure this.” Clear measures and goals are crucial in any Lean experiment, says Burnworth, in order to compare the new and old processes and to give everyone a firm sense of exactly what they want to accomplish and improve.
After a few days of getting the necessary gear in place, the two-week pilot of the new triage process began.
After two weeks, the measures showed undoubtedly that the pilot had improved outcomes for triage patients:
- The total number of reminders sent from Nurses working on triage to Providers had reduced by almost half.
- The number of medical clinic requests from triage had been reduced by over 60%, meaning that patients were able to get their needs met by providers and nurses working together at the triage post rather than having to wait to be seen in the clinic.
- The volume of medications to fill reminders that normally would have been reviewed by providers after the patient was seen were reduced by half because the provider could see the patient on the spot.
The people doing the work also learned other ways to improve care simply by working together.
Before the pilot, nurses had been relaying triage assessments to the providers, but the providers couldn’t see what the nurses were seeing. For example, with a particularly bad case of athlete’s foot, a provider might read “athlete’s foot” in the nurse’s notes and not appreciate the severity of the case. Working side-by-side, the providers could better see some of the nuances in the cases the nurses were seeing and develop standard descriptions that everyone would understand.
Likewise, the two could share feedback more effectively. In the old system, because providers wouldn’t see patient notes until hours after nurses had done the triage, it was hard for providers to give feedback to nurses on how well those notes communicated the details. And nurses might not know at all what decisions the providers had reached about patient treatment.
By working together, the nurses and providers were able to reduce variability in the provision of care.
Future continuous improvement in the Jail Health system will be patient centered, says Sanders, including changes to this new triage approach.
Indeed, Sanders intends to monitor other areas of medical provision to make sure that these triage teams really are the most effective use of nurse and provider time. This new approach may be better than the old way, but continuous improvement means always looking for other, even better ways of providing care to patients.
Officer Anthony Farrell explains the importance of focusing on the patient, even in a corrections setting. “We are their only medical service provider for some of these individuals. This tightens up the time span between when the person gets seen and treated and allows the medicals staff to address important medical concerns. If someone who is seriously ill we can catch and deal with it sooner.”
As Sanders, Farrell, and others are aware, when inmate-patients would be released before they could receive treatment, that not only failed them as individuals, but also created a public health gap. Quicker definitive treatment increases the jail’s leverage as a public health provider to an underserved population.
Christopher Derrah, Registered Nurse
Casey Dooley, Registered Nurse
Sean Dumas, Nursing Supervisor
Anthony Farrell, Corrections Officer
Jennifer Jones-Vanderleest, Physician
Ben Sanders, KCCF Medical Director
Catherine Schroeder, Nurse Practitioner