- Email: [email protected]
Improving Surgical Start Times by Improving Wayfinding
Journal of PeriAnesthesia Nursing xxx (xxxx) xxx
Contents lists available at ScienceDirect
Journal of PeriAnesthesia Nursing journal homepage: www.jopan.org
Original Article
Improving Surgical Start Times by Improving Wayfinding Esther Lee, MNP, MBA, CEHL, RN a, *, JoAnn Daugherty, PhD, RN, CNL a, b, Joanne T. Selga, BSN, RN, CCRN-CMC a, Ulrich Schmidt, MBA, PhD, MD c a
Perianesthesia Services, UC San Diego Health, San Diego, CA School of Nursing, California State University, San Marcos, CA c Critical Care Medicine, University of California San Diego, CA b
a b s t r a c t Keywords: Plan, Do, Study, Act (PDSA) cycles preoperative area (POA) path of travel wayfinding signage
Purpose: This performance improvement project was undertaken to reduce costly delays in first-case, operating room (OR) start times. Design: Two Plan, Do, Study, Act (PDSA) cycles. Methods: In PDSA 1, student nurses observed 30 patients' paths of travel from hospital entrance to OR and documented time spent at key stopping points. Directional signs were placed after PDSA 1. PDSA 2 consisted of an electronic medical record (EMR) review of pre- and postsignage cases (n ¼ 492 and n ¼ 538 respectively). Findings: In the initial PDSA cycle (n ¼ 30), one reason for delay was the time patients spent finding the preoperative area (POA). Signage was placed at strategic points noted to confuse patients. PDSA cycle 2 found median presignage POA arrival times (34 minutes) were significantly higher than postsignage POA arrival times (20 minutes) (U ¼ 51,618.0, z ¼ 16.934, P < .001). Conclusions: Delayed wayfinding contributed to delayed OR starts but improved with appropriate signage. © 2019 American Society of PeriAnesthesia Nurses. Published by Elsevier, Inc. All rights reserved.
Efficient use of operating room (OR) time is a priority in cost containment and improving reimbursements. Much has been written about late starts in the OR, especially with first cases, creating inefficient workflow for the rest of the surgical day.1-3 Bauer et al1 studied delayed starts for over a year in their threehospital, Midwestern health system and estimated a revenue loss of $519,388.00. On-time start was defined as in-room time that is equal to or before the scheduled surgical time. Causes of delay reported by these authors and others include late arrivals by patients, surgeon-related factors (late arrival), anesthesia provider factors if no preoperative clinic evaluation was performed, malfunctioning equipment, and lack of completed consent.1-3 Using the Plan, Do, Study, Act (PDSA) model, a performance improvement project (PDSA 1) was completed to identify the sources of delay within our institution. Using the findings of the completed first PDSA cycle, we completed a second PDSA cycle (PDSA 2) to evaluate the actions implemented to reduce delays in
Conflict of interest: None to report. * Address correspondence to Esther Lee, UC San Diego Health, 200 West Arbor Dr., #8708, San Diego, CA 92103-8708 E-mail address: [email protected].
first-case starts. The target outcome was to reduce the time to start of surgery. No cost analysis was performed. PDSA 1 PDSA 1: Plan In our urban, southwestern United States (US) academic medical center, we observed late starts for both first and subsequent cases on the surgical day. After a literature review to determine common causes of delays in surgical starts, we focused on the first PDSA cycle to determine where patients lost time in our facility on the way to the preoperative area (POA). PDSA 1: Do We observed the patient flow from the front door of the hospital to the departure from the POA to the OR. Nursing students greeted patients at the front door and followed them through the process of checking in and walking to the preoperative waiting area without interfering in the patients' attempts to find their own way. The students were provided a checklist of key tasks that were to be
https://doi.org/10.1016/j.jopan.2019.06.001 1089-9472/$36.00/© 2019 American Society of PeriAnesthesia Nurses. Published by Elsevier, Inc. All rights reserved.
2
E. Lee et al. / Journal of PeriAnesthesia Nursing xxx (xxxx) xxx
completed in the process of preoperative preparation, and they wrote in the time when each of these key tasks occurred. These included tasks completed by the patient, physicians, and nursing staff (see Figure 1). This process was completed for 30 patients. The students also compared their direct observation times to the times logged in the electronic medical record (EMR) to determine if data could be extracted from the EMR for future observations. The computer login occurred when the patients checked-in at the admissions desk or kiosks. PDSA 1: Study Of the 30 patients followed by students, two patients arrived very early due to their confusion about their assigned report times. They were not included in the final analysis. Of the 16 first-case starts, 9 (56.3%) faced delay in going to the OR, and of the 12 nonefirst-case starts, 7 (58.3%) were delayed. Causes for delay included patient factors, staff factors, and physician factors. Patient factors included arriving late for the procedure (5 patients), mobility impairment (use of assistive devices such as cane or walker) increasing length of time from arrival time to preoperative unit doors (2 patients), and having difficulty finding the way from hospital entrance to preoperative waiting area (4 patients). It should be noted that the hospital entrance is at the opposite end from the preoperative unit in two connected medical buildings. The path of travel requires patients to walk down a long hallway and take an elevator to the second floor. The nursing students observed that patients were frequently confused even though staff at the front entrance and those at the check-in desk or kiosks gave verbal directions twice. The way was not clearly marked with signage from the patient's perspective. Even patients who were not late arriving to the preoperative unit were overheard expressing confusion about which way to go.
Staff factors influencing a delay in arrival inside the POA included (1) patients and family meeting outside of the POA with a surgical liaison to be escorted from the first floor to the second floor waiting area. The liaison also obtains contact information and briefs the patients and family on what to expect during the perioperative period and (2) patients waiting for preoperative staff to come to the waiting area and escort them to their preoperative cubicle. Other factors contributing to delays included incomplete surgical consents, need for translation services, patients who had not completed the chlorhexidine bathing protocol before arrival, and system delays that would require multidisciplinary meetings and approaches. Having identified the loss of 30 minutes due to difficulty with wayfinding to the POA, our team chose to focus on this issue as it was within our scope to resolve with the least difficulty. PDSA 1: Act Based on the finding of a 30-minute transit time from the hospital entrance to arriving inside the POA, the liaison waited for patients in the preoperative waiting area rather than greeting them on the first floor and bringing them to the second floor personally. Although meeting arriving patients on the first floor was intended to be good customer service, it was creating delays in preoperative preparation. Second, we increased the number of POA staff who came out to the waiting area to escort the first-case patients into the POA. Previously, the surgical liaison and certified nurse aides would perform this function, and nurses were in the POA preparing rooms and charts. The six nurses on duty began assisting with the patient rooming process for first-case patients. The third change was to improve wayfinding for patients through additional signage. Sufficient wall signage was lacking. The student observers noticed the key points that patients seemed to get confused in finding their way. Their findings confirmed what
Pre-Op Check-in Timing Process
Pre-Op Check-in Timing Process
Hospital arrival me: ______
Hospital arrival me: ______
(epic) Kiosk start me: _____ Kiosk Completed: _______
(epic) Kiosk start me: ______ Kiosk Completed: _______
Pre-Op Physical Arrival Time at Door: _______
Pre-Op Arrival Time: _______
CCP check in: ________ Out: _______
CCP check in: ________ Out: _______
Approx. changing me: ______ mins (self / assist)
Approx. changing me: ______ mins (self / assist)
RN in room: _________ Out: ______
RN in room: _________ Out: ______
Anesthesia in room: _______ Out: ______
Anesthesia in room: _______ Out: ______
OR RN in room: ________ Out: _______
OR RN in room: ________ Out: _______
Surgeon in room: ________ Out: _______
Surgery in room: ________ Out: _______
(Epic)Interval note done: ________ (me)
(Epic)Interval note done: ________ (me)
(Epic) Pre-op Complete: ________
(epic) Pre-op Complete: ________
Handoff Time: ______
Handoff Time: ______
Pt to OR: ________
Pt to OR: ________
Mar Used: Yes / No
Mar Used: Yes / No
Block Paent: Yes / No
Block Paent: Yes / No
Block team in room: ________ Out: ________
Block team in room: ________ Out: ________
RN________________ Charge RN _______________
RN________________ Charge RN _______________
RN issues encountered: (to be completed by RN)
RN issues encountered: (to be completed by RN)
________________________________________
________________________________________
Figure 1. Preop time flow tracker. CCP, clinical care partner; OR, operating room; RN, registered nurse.
E. Lee et al. / Journal of PeriAnesthesia Nursing xxx (xxxx) xxx
management team assumed might be the case. The three changes described previously were studied in the second PDSA cycle. PDSA 2 PDSA 2: Plan Wayfinding is a process of navigating from one space to another, a form of information processing which begins with recognizing landmark along the path of travel, in the process acquiring route knowledge and ending with developing an overall map of the environment.4 Wayfinding is particularly important in complex systems such as large health care facilities. Allison5 argues that hospitals exhibit many similar features of a city as manifested in the hierarchy of circulation, with nodes and landmarks (department entrances, nurses' stations, courtyards and gardens) as reference points along the paths of travels.
3
Colette6 noted that whatever wayfinding information is installed in a hospital, people may find it challenging to see, understand, and follow. Patients (customers) and visitors (guests)7 are often distracted by the reason why they are in the hospital. They can be stressed, confused, nervous, and upset, and these stressors affect their ability to process information.6 In our experience, the team found the stress and confusion factors to be true of our patient population, particularly among the elderly. Verbal instructions from hospital admissions staff at two different points along the first-floor pathway was not sufficient for wayfinding down the long hallway and up to the second floor. Based on student observers' reports on the locations where patients were most likely to get confused or lost in wayfinding, the team sought permission to place directional signs at five key locations. To address the issues of patient flow once greeted by the surgical liaison and staff delays in escorting patients into the POA, our team
Figure 2. Protocol for revised patient flow from PDSA 1 to PDSA 2; CCP ¼ Clinical Care Partner, institutional title for Certified Nurses' Aide; HUC, Hospital Unit Coordinator, institutional title for unit secretary and receptionist role; PDSA, Plan, Do, Study, Act.
4
E. Lee et al. / Journal of PeriAnesthesia Nursing xxx (xxxx) xxx
Table 1 Comparison of First-Case Start Time Intervals for Key Steps in Wayfinding
PDSA 1 PDSA 2 Difference
Time From Front Door to Check-In Location
Check-In Kiosk
Second Floor Waiting Area
Surgical Liaison Intro
Entrance into the POA
Total Time
2.59 2.82 þ0.23
7.12 2.94 4.18
14.38 3.75 10.63
7.41 3.94 3.47
0.88 3.06 þ 2.18
33.29 20.98 12.31
PDSA, Plan, Do, Study, Act; POA, preoperative area. N ¼ 55 first-case patients in PDSA 2; time intervals are expressed in minutes.
conducted a meeting with all the stakeholders to implement the three changes described previously. Stakeholders were identified as the POA nurse managers, POA charge nurse representatives, surgical liaison representative, liaisons' manager, and POA nurse educator. Respectful communication was very important in ensuring success in changes. It was important that charge nurses not feel blamed for late starts in their daily leadership of the unit, and it is also equally important that the surgical liaisons not feel disrespected or pushed aside by asking them to alter their workflow to reduce the time spent greeting and orienting patients. The nurse manager developed a protocol for revised flow within the POA, and the staff was educated on the process. This protocol reflected the agreements made in the stakeholders meeting (Figure 2). This protocol addressed the first two findings of PDSA 1: reducing time that the surgical liaison spent waiting to meet and escort patients to the waiting area and increasing the number of nursing staff bringing first-case starts from the waiting area to the preoperative cubicle. PDSA 2: Do Directional signs were placed, and the protocol to reduce delays of arrival into POA was implemented. Ongoing communication among surgical liaisons, charge nurses, and nursing support staff was crucial to the success of even minor changes in the workflow of rooming patients in the POA cubicles. Using the same data collection tool in Figure 1, a second set of nursing students performed data collection on wayfinding by patients from the front door hospital entrance to the POA waiting area. These students observed if patients appeared to follow the
directions on signs or if they took a wrong turn despite the signs. In addition, data were extracted from the EMR to look at check-in times logged by admissions staff. This direct observation process by nursing students followed 55 patients. The students also compared their observed times to EMR times for check-in to determine if data could be extracted from the EMR for future observations. Once it was confirmed that the direct observation times and computer login times for check-in were within an acceptable margin, additional check-in times were pulled from the EMR to compare the travel time from check-in to arrival in the POA. PDSA 2: Study Table 1 depicts the overall reduction of time from “front door check-in to POA” by 12.31 minutes after the three changes were initiated. These times were recorded by the student observers for 55 patients. The total time to entering POA was reduced by 12.31 minutes. This was a 37% reduction in time from PDSA 1 to PDSA 2. The liaisons reduced their time from 7.41 minutes to 3.75 minutes (47%), whereas the staff time escorting patients into the POA increased by 2.18 minutes. This may be due to the additional six nursing staff escorting patients through a single entrance to the unit. A noticeable reduction in the total time from check-in kiosk to second floor waiting area of 10.63 minutes made a huge contribution in reducing the total time. This is most likely attributable to the additional signage used to support wayfinding by the patients. Once again, the students determined their observation times closely matched EMR times showing admission area check-in and arrival in POA.
37
AVERAGE MINUTES
36
AVERAGE ADMIT TO PRE OP MINUTES
22
21
Pre-signage Month 1 Pre-signage Month 2 Post-Signage Month 1 Post-Signage Month 2
PRE-SIGNAGE MONTH 1
PRE-SIGNAGE MONTH 2
POST-SIGNAGE MONTH 1
POST-SIGNAGE MONTH 2
Pre-signage Month 1: n=249 Pre-signage Month 2: n=243 Post-signage Month 1: n=276 Post-signage Month 2:n=262
Figure 3. Reductions in average times to POA admission. This figure is available in color online at www.jopan.org.
E. Lee et al. / Journal of PeriAnesthesia Nursing xxx (xxxx) xxx
Using the data extracted from the EMR, we compared 2 months of presignage check-in time data (n ¼ 492) with 2 months of postsignage check-in data. Figure 3 shows the graphic results of cases reviewed. In addition, the medians of the presignage and postsignage times were compared using the Mann-Whitney U test as the data showed a nonnormal distribution. The median presignage times (34 minutes) were statistically significantly higher than the postsignage times (20 minutes) (U ¼ 51,618.0, z ¼ 16.934, P < .001).
5
Conclusions Signage has reduced our delay in preparing patients for surgery in the POA. PDSA cycles helped our team determine difficulties in wayfinding as a major source of patient delay and allowed us to find and evaluate signage as a solution for the problem.
PDSA 2: Act
References
Wayfinding was one of the biggest challenges to overcome for on-time surgical starts. The addition of simple signage at key points facilitated this reduction. Given the large number of Spanishspeaking patients in our area, the team is considering adding Spanish to the signage. Alternate solutions also included changing the entrance in which patients enter the facility. The patient entrance reported in this project was chosen because it is more familiar to long-time patients and closer to parking structures. However, this entrance promotes frustration among patients and visitors as well as delays in arrival time in POA. The literature cited in this article supports that patient frustration with difficulty in wayfinding leads to anxiety and confusion. The staff providing presurgical education to patients will provide a map and direct patients to the closest entrance to the POA. Further evaluation of time to POA arrival and patient satisfaction will determine if this is a better route.
1. Cox Bauer CM, Greer DM, Vander Wyst KB, Kamelle SA. First-case operating room delays: patterns across urban hospitals of a single health care system. J Patient-Centered Res Rev. 2016;3:125e135. 2. Deldar R, Soleimani T, Harmon C, et al. Improving first case start times using Lean in an academic medical center. Am J Surg. 2017;213: 991e995. 3. Tsai MH, Hudson ME, Emerick TD, McFadden DW. The true relevance of first-case start delays. Am J Surg. 2015;209:427e429. 4. Sadek AH. A comprehensive approach to facilitate wayfinding in healthcare facilities. In: Design4Health: Proceedings of the 3rd European Conference on Design4Health. July 13-16, 2015. Sheffield, UK. 5. Allison D. Hospital as city: employing urban design strategies for effective wayfinding. Health Facil Manag. 2007;20:61. 6. Colette Jeffrey B. Hospital wayfinding: Whose job is it?; 2011. Available at: https:// www.researchgate.net/profile/Colette_Jeffrey/publication/285334256_Hospital_ wayfinding_Whose_job_is_it_Presented_at_Include_2011_at_the_Royal_College _of_Arts_London/links/565d74e408ae4988a7bc01e0/Hospital-wayfinding-Who se-job-is-it-Presented-at-Include-2011-at-the-Royal-College-of-Arts-London. pdf. Accessed September 12, 2018. 7. Carpman JR, Grant MA. Design That Cares: Planning Health Facilities for Patients and Visitors. Vol. 142. Hoboken, NJ: John Wiley & Sons; 2016.
Contents lists available at ScienceDirect
Journal of PeriAnesthesia Nursing journal homepage: www.jopan.org
Original Article
Improving Surgical Start Times by Improving Wayfinding Esther Lee, MNP, MBA, CEHL, RN a, *, JoAnn Daugherty, PhD, RN, CNL a, b, Joanne T. Selga, BSN, RN, CCRN-CMC a, Ulrich Schmidt, MBA, PhD, MD c a
Perianesthesia Services, UC San Diego Health, San Diego, CA School of Nursing, California State University, San Marcos, CA c Critical Care Medicine, University of California San Diego, CA b
a b s t r a c t Keywords: Plan, Do, Study, Act (PDSA) cycles preoperative area (POA) path of travel wayfinding signage
Purpose: This performance improvement project was undertaken to reduce costly delays in first-case, operating room (OR) start times. Design: Two Plan, Do, Study, Act (PDSA) cycles. Methods: In PDSA 1, student nurses observed 30 patients' paths of travel from hospital entrance to OR and documented time spent at key stopping points. Directional signs were placed after PDSA 1. PDSA 2 consisted of an electronic medical record (EMR) review of pre- and postsignage cases (n ¼ 492 and n ¼ 538 respectively). Findings: In the initial PDSA cycle (n ¼ 30), one reason for delay was the time patients spent finding the preoperative area (POA). Signage was placed at strategic points noted to confuse patients. PDSA cycle 2 found median presignage POA arrival times (34 minutes) were significantly higher than postsignage POA arrival times (20 minutes) (U ¼ 51,618.0, z ¼ 16.934, P < .001). Conclusions: Delayed wayfinding contributed to delayed OR starts but improved with appropriate signage. © 2019 American Society of PeriAnesthesia Nurses. Published by Elsevier, Inc. All rights reserved.
Efficient use of operating room (OR) time is a priority in cost containment and improving reimbursements. Much has been written about late starts in the OR, especially with first cases, creating inefficient workflow for the rest of the surgical day.1-3 Bauer et al1 studied delayed starts for over a year in their threehospital, Midwestern health system and estimated a revenue loss of $519,388.00. On-time start was defined as in-room time that is equal to or before the scheduled surgical time. Causes of delay reported by these authors and others include late arrivals by patients, surgeon-related factors (late arrival), anesthesia provider factors if no preoperative clinic evaluation was performed, malfunctioning equipment, and lack of completed consent.1-3 Using the Plan, Do, Study, Act (PDSA) model, a performance improvement project (PDSA 1) was completed to identify the sources of delay within our institution. Using the findings of the completed first PDSA cycle, we completed a second PDSA cycle (PDSA 2) to evaluate the actions implemented to reduce delays in
Conflict of interest: None to report. * Address correspondence to Esther Lee, UC San Diego Health, 200 West Arbor Dr., #8708, San Diego, CA 92103-8708 E-mail address: [email protected].
first-case starts. The target outcome was to reduce the time to start of surgery. No cost analysis was performed. PDSA 1 PDSA 1: Plan In our urban, southwestern United States (US) academic medical center, we observed late starts for both first and subsequent cases on the surgical day. After a literature review to determine common causes of delays in surgical starts, we focused on the first PDSA cycle to determine where patients lost time in our facility on the way to the preoperative area (POA). PDSA 1: Do We observed the patient flow from the front door of the hospital to the departure from the POA to the OR. Nursing students greeted patients at the front door and followed them through the process of checking in and walking to the preoperative waiting area without interfering in the patients' attempts to find their own way. The students were provided a checklist of key tasks that were to be
https://doi.org/10.1016/j.jopan.2019.06.001 1089-9472/$36.00/© 2019 American Society of PeriAnesthesia Nurses. Published by Elsevier, Inc. All rights reserved.
2
E. Lee et al. / Journal of PeriAnesthesia Nursing xxx (xxxx) xxx
completed in the process of preoperative preparation, and they wrote in the time when each of these key tasks occurred. These included tasks completed by the patient, physicians, and nursing staff (see Figure 1). This process was completed for 30 patients. The students also compared their direct observation times to the times logged in the electronic medical record (EMR) to determine if data could be extracted from the EMR for future observations. The computer login occurred when the patients checked-in at the admissions desk or kiosks. PDSA 1: Study Of the 30 patients followed by students, two patients arrived very early due to their confusion about their assigned report times. They were not included in the final analysis. Of the 16 first-case starts, 9 (56.3%) faced delay in going to the OR, and of the 12 nonefirst-case starts, 7 (58.3%) were delayed. Causes for delay included patient factors, staff factors, and physician factors. Patient factors included arriving late for the procedure (5 patients), mobility impairment (use of assistive devices such as cane or walker) increasing length of time from arrival time to preoperative unit doors (2 patients), and having difficulty finding the way from hospital entrance to preoperative waiting area (4 patients). It should be noted that the hospital entrance is at the opposite end from the preoperative unit in two connected medical buildings. The path of travel requires patients to walk down a long hallway and take an elevator to the second floor. The nursing students observed that patients were frequently confused even though staff at the front entrance and those at the check-in desk or kiosks gave verbal directions twice. The way was not clearly marked with signage from the patient's perspective. Even patients who were not late arriving to the preoperative unit were overheard expressing confusion about which way to go.
Staff factors influencing a delay in arrival inside the POA included (1) patients and family meeting outside of the POA with a surgical liaison to be escorted from the first floor to the second floor waiting area. The liaison also obtains contact information and briefs the patients and family on what to expect during the perioperative period and (2) patients waiting for preoperative staff to come to the waiting area and escort them to their preoperative cubicle. Other factors contributing to delays included incomplete surgical consents, need for translation services, patients who had not completed the chlorhexidine bathing protocol before arrival, and system delays that would require multidisciplinary meetings and approaches. Having identified the loss of 30 minutes due to difficulty with wayfinding to the POA, our team chose to focus on this issue as it was within our scope to resolve with the least difficulty. PDSA 1: Act Based on the finding of a 30-minute transit time from the hospital entrance to arriving inside the POA, the liaison waited for patients in the preoperative waiting area rather than greeting them on the first floor and bringing them to the second floor personally. Although meeting arriving patients on the first floor was intended to be good customer service, it was creating delays in preoperative preparation. Second, we increased the number of POA staff who came out to the waiting area to escort the first-case patients into the POA. Previously, the surgical liaison and certified nurse aides would perform this function, and nurses were in the POA preparing rooms and charts. The six nurses on duty began assisting with the patient rooming process for first-case patients. The third change was to improve wayfinding for patients through additional signage. Sufficient wall signage was lacking. The student observers noticed the key points that patients seemed to get confused in finding their way. Their findings confirmed what
Pre-Op Check-in Timing Process
Pre-Op Check-in Timing Process
Hospital arrival me: ______
Hospital arrival me: ______
(epic) Kiosk start me: _____ Kiosk Completed: _______
(epic) Kiosk start me: ______ Kiosk Completed: _______
Pre-Op Physical Arrival Time at Door: _______
Pre-Op Arrival Time: _______
CCP check in: ________ Out: _______
CCP check in: ________ Out: _______
Approx. changing me: ______ mins (self / assist)
Approx. changing me: ______ mins (self / assist)
RN in room: _________ Out: ______
RN in room: _________ Out: ______
Anesthesia in room: _______ Out: ______
Anesthesia in room: _______ Out: ______
OR RN in room: ________ Out: _______
OR RN in room: ________ Out: _______
Surgeon in room: ________ Out: _______
Surgery in room: ________ Out: _______
(Epic)Interval note done: ________ (me)
(Epic)Interval note done: ________ (me)
(Epic) Pre-op Complete: ________
(epic) Pre-op Complete: ________
Handoff Time: ______
Handoff Time: ______
Pt to OR: ________
Pt to OR: ________
Mar Used: Yes / No
Mar Used: Yes / No
Block Paent: Yes / No
Block Paent: Yes / No
Block team in room: ________ Out: ________
Block team in room: ________ Out: ________
RN________________ Charge RN _______________
RN________________ Charge RN _______________
RN issues encountered: (to be completed by RN)
RN issues encountered: (to be completed by RN)
________________________________________
________________________________________
Figure 1. Preop time flow tracker. CCP, clinical care partner; OR, operating room; RN, registered nurse.
E. Lee et al. / Journal of PeriAnesthesia Nursing xxx (xxxx) xxx
management team assumed might be the case. The three changes described previously were studied in the second PDSA cycle. PDSA 2 PDSA 2: Plan Wayfinding is a process of navigating from one space to another, a form of information processing which begins with recognizing landmark along the path of travel, in the process acquiring route knowledge and ending with developing an overall map of the environment.4 Wayfinding is particularly important in complex systems such as large health care facilities. Allison5 argues that hospitals exhibit many similar features of a city as manifested in the hierarchy of circulation, with nodes and landmarks (department entrances, nurses' stations, courtyards and gardens) as reference points along the paths of travels.
3
Colette6 noted that whatever wayfinding information is installed in a hospital, people may find it challenging to see, understand, and follow. Patients (customers) and visitors (guests)7 are often distracted by the reason why they are in the hospital. They can be stressed, confused, nervous, and upset, and these stressors affect their ability to process information.6 In our experience, the team found the stress and confusion factors to be true of our patient population, particularly among the elderly. Verbal instructions from hospital admissions staff at two different points along the first-floor pathway was not sufficient for wayfinding down the long hallway and up to the second floor. Based on student observers' reports on the locations where patients were most likely to get confused or lost in wayfinding, the team sought permission to place directional signs at five key locations. To address the issues of patient flow once greeted by the surgical liaison and staff delays in escorting patients into the POA, our team
Figure 2. Protocol for revised patient flow from PDSA 1 to PDSA 2; CCP ¼ Clinical Care Partner, institutional title for Certified Nurses' Aide; HUC, Hospital Unit Coordinator, institutional title for unit secretary and receptionist role; PDSA, Plan, Do, Study, Act.
4
E. Lee et al. / Journal of PeriAnesthesia Nursing xxx (xxxx) xxx
Table 1 Comparison of First-Case Start Time Intervals for Key Steps in Wayfinding
PDSA 1 PDSA 2 Difference
Time From Front Door to Check-In Location
Check-In Kiosk
Second Floor Waiting Area
Surgical Liaison Intro
Entrance into the POA
Total Time
2.59 2.82 þ0.23
7.12 2.94 4.18
14.38 3.75 10.63
7.41 3.94 3.47
0.88 3.06 þ 2.18
33.29 20.98 12.31
PDSA, Plan, Do, Study, Act; POA, preoperative area. N ¼ 55 first-case patients in PDSA 2; time intervals are expressed in minutes.
conducted a meeting with all the stakeholders to implement the three changes described previously. Stakeholders were identified as the POA nurse managers, POA charge nurse representatives, surgical liaison representative, liaisons' manager, and POA nurse educator. Respectful communication was very important in ensuring success in changes. It was important that charge nurses not feel blamed for late starts in their daily leadership of the unit, and it is also equally important that the surgical liaisons not feel disrespected or pushed aside by asking them to alter their workflow to reduce the time spent greeting and orienting patients. The nurse manager developed a protocol for revised flow within the POA, and the staff was educated on the process. This protocol reflected the agreements made in the stakeholders meeting (Figure 2). This protocol addressed the first two findings of PDSA 1: reducing time that the surgical liaison spent waiting to meet and escort patients to the waiting area and increasing the number of nursing staff bringing first-case starts from the waiting area to the preoperative cubicle. PDSA 2: Do Directional signs were placed, and the protocol to reduce delays of arrival into POA was implemented. Ongoing communication among surgical liaisons, charge nurses, and nursing support staff was crucial to the success of even minor changes in the workflow of rooming patients in the POA cubicles. Using the same data collection tool in Figure 1, a second set of nursing students performed data collection on wayfinding by patients from the front door hospital entrance to the POA waiting area. These students observed if patients appeared to follow the
directions on signs or if they took a wrong turn despite the signs. In addition, data were extracted from the EMR to look at check-in times logged by admissions staff. This direct observation process by nursing students followed 55 patients. The students also compared their observed times to EMR times for check-in to determine if data could be extracted from the EMR for future observations. Once it was confirmed that the direct observation times and computer login times for check-in were within an acceptable margin, additional check-in times were pulled from the EMR to compare the travel time from check-in to arrival in the POA. PDSA 2: Study Table 1 depicts the overall reduction of time from “front door check-in to POA” by 12.31 minutes after the three changes were initiated. These times were recorded by the student observers for 55 patients. The total time to entering POA was reduced by 12.31 minutes. This was a 37% reduction in time from PDSA 1 to PDSA 2. The liaisons reduced their time from 7.41 minutes to 3.75 minutes (47%), whereas the staff time escorting patients into the POA increased by 2.18 minutes. This may be due to the additional six nursing staff escorting patients through a single entrance to the unit. A noticeable reduction in the total time from check-in kiosk to second floor waiting area of 10.63 minutes made a huge contribution in reducing the total time. This is most likely attributable to the additional signage used to support wayfinding by the patients. Once again, the students determined their observation times closely matched EMR times showing admission area check-in and arrival in POA.
37
AVERAGE MINUTES
36
AVERAGE ADMIT TO PRE OP MINUTES
22
21
Pre-signage Month 1 Pre-signage Month 2 Post-Signage Month 1 Post-Signage Month 2
PRE-SIGNAGE MONTH 1
PRE-SIGNAGE MONTH 2
POST-SIGNAGE MONTH 1
POST-SIGNAGE MONTH 2
Pre-signage Month 1: n=249 Pre-signage Month 2: n=243 Post-signage Month 1: n=276 Post-signage Month 2:n=262
Figure 3. Reductions in average times to POA admission. This figure is available in color online at www.jopan.org.
E. Lee et al. / Journal of PeriAnesthesia Nursing xxx (xxxx) xxx
Using the data extracted from the EMR, we compared 2 months of presignage check-in time data (n ¼ 492) with 2 months of postsignage check-in data. Figure 3 shows the graphic results of cases reviewed. In addition, the medians of the presignage and postsignage times were compared using the Mann-Whitney U test as the data showed a nonnormal distribution. The median presignage times (34 minutes) were statistically significantly higher than the postsignage times (20 minutes) (U ¼ 51,618.0, z ¼ 16.934, P < .001).
5
Conclusions Signage has reduced our delay in preparing patients for surgery in the POA. PDSA cycles helped our team determine difficulties in wayfinding as a major source of patient delay and allowed us to find and evaluate signage as a solution for the problem.
PDSA 2: Act
References
Wayfinding was one of the biggest challenges to overcome for on-time surgical starts. The addition of simple signage at key points facilitated this reduction. Given the large number of Spanishspeaking patients in our area, the team is considering adding Spanish to the signage. Alternate solutions also included changing the entrance in which patients enter the facility. The patient entrance reported in this project was chosen because it is more familiar to long-time patients and closer to parking structures. However, this entrance promotes frustration among patients and visitors as well as delays in arrival time in POA. The literature cited in this article supports that patient frustration with difficulty in wayfinding leads to anxiety and confusion. The staff providing presurgical education to patients will provide a map and direct patients to the closest entrance to the POA. Further evaluation of time to POA arrival and patient satisfaction will determine if this is a better route.
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