Operations Improvement Plan

Introduction

It is important that every healthcare employee that may be involved in the direct care of a patient with any type of injury or disease be knowledgeable of the processes that govern the delivery of care to such a patient population. This paper will follow a patient with Gall Bladder disease and examine the processes within the Emergency room, the Radiology Department, and the Operating Room, and identifies possible flaws that may arise.

Emergency room care is one of the first processes that a patient would encounter. Each patient is carefully evaluated, various diagnostic tests ordered and performed, and based on these results, given an accurate diagnosis. Another department is radiology. The three sub-processes that take place in the radiology department are, 1) plain radiographic films, 2) computerized tomography scans, and 3) gall bladder ultrasounds. The main components of these sub-processes are utilization, productivity, efficiency, capacity, scheduling, inventory control, and information exchange. The final process is that of the operating room. There are four sub-processes within the operating room they are: 1) the secretarial, 2) the anesthesia, 3) the charge, and 4) the central supply. Physicians play the most significant role in determining the appropriate care for the patient and whether surgery is needed and how soon it is to be performed. Regardless of the patient status, all these processes must be functioning at their maximum potential level in order for the patient to receive adequate care.

The Process in the Emergency Room

Upon entering the Emergency Room, a patient must sign in and state a chief complaint. The triage nurse reviews the signed in patients and triages according to the acuity of the chief complaint. The typical patient with cholecystitis will present with complaints of right upper quadrant abdominal pain, nausea, and fever. This patient would receive an acuity rating of II. Level I acuity is considered non-urgent, level II acuity is considered urgent, and level III is considered emergent (see triage step.)

Level II acuity patients must be placed in a patient room within two hours of arrival to the Emergency Room. Typically, this patient would be evaluated by the triage nurse and placed in the waiting room until a room becomes available. The patient's waiting time is not expected to exceed two hours.

Once the patient is placed in a room, he/she is re-evaluated by a nurse, and within 10 minutes by a physician. At this point the patient is asked basically the same questions 3 times. Upon completion of the physicians' examination, intravenous therapy is initiated, lab work is drawn and medications are given. This process usually takes approximately 30 minutes.

The next phase of care for the patient with suspected cholecystitis is an abdominal series x-ray, followed by a CT-scan, and then gall bladder ultrasound. The patient is sent to the radiology department for the abdominal series then returned to their room. The patient is then administered oral contrast for the

CT-scan. The patient may not proceed to the CT-scan until 2 hours after oral contrast administration. While waiting for two hours, lab results are usually received, and a request for a surgical consultation is made.

Depending on the patient census in the Emergency Department, the wait for CT-scan can vary. CT-scans are performed on an acuity basis, and emergent patients are placed at the top of the list. Often there is a lengthy wait to go to the CT-scan department. In addition, if the patient census is high in the Emergency Department, or in the Operating Room, there can be delays in receiving a surgical consultation.

Once the patient has completed the scan and has been evaluated by a surgeon, the patient is posted for surgery. The surgeon schedules the surgery in collaboration with the Operating Room. The patient must remain in the Emergency Room until he/she is transferred to the operating room. This wait can vary depending on the census in the Operating Room. During the wait, the patient must sign the surgical consent form. They may also receive pre-operative medications. At this point, the anesthesiologist is supposed to evaluate the patient and his/her medical history. Usually, and additional intravenous line is started and additional lab work may be drawn. Once these steps have been completed, the patient proceeds to the Operating Room.

Identified Flaws

* Excessive waiting times.

* Patient asked repetitive questions by multiple staff members and physicians.

* Delays in Radiology Department.

* Delays with laboratory results.

* Lack of communication between departments

* Lack of communication between staff and physicians.

Recommendations

In order to improve on some of the issues that are described in this document. Recommendations are a follows:

 Create protocols for commonly seen problems. This allows nurses to get a head start on sending labs, getting x-rays and giving medications. This can even be initiated at triage.

 Create working teams of physicians and nurses. Assign the team a group of rooms and have them see the patient together. Have physicians give verbal orders so the nurse can get started on patient care, the physician can then write orders and follow up on other patients.

 Keep a portable x-ray machine in the Emergency Center.

 Train nursing staff to perform their own EKG's instead of waiting on EKG technicians.

 Require nurses to draw blood samples from patients rather than waiting on a lab technician.

 Increase emergency room personnel during peak times.

 Utilize Emergency Center technicians to transport patients rather than wait on main hospital transportation.

 Create an after-hours care center for non-acute patient population. This frees up the emergency room for patients that are more critical.

The Process in the Radiology Department

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