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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Issue 11 

Carrie Ceppi-RogulkinTina Little


The achievement of measurable organizational, patient,
workforce and community outcomes through quality, safety
and performance improvement processes.

By Carrie Ceppi-Rogulkin, MSN, RN, CPNP and Tina Little, BSN, RN

Orthopaedics Goes LEAN!


The orthopaedic practice of Children’s Hospital Central California has grown by more than 20 percent over the past 10 years, yet few of the outpatient clinic processes have changed. Today, visits to the Hospital’s largest outpatient department exceed 23,000 per year. Hospital management selected two departments to be the first areas to use a LEAN workshop for process improvements. The workshops are called Rapid Process Improvement (RPI) workshops. Our weeklong workshop took place Sept. 19–23, 2011. This article will explain the LEAN process as well as how it applied to orthopaedics and our current results.

Based on systems used by other companies, the principles of LEAN management eliminate or decrease nonvalue-added steps and can be applied to any process, such as patient flow throughout a clinic. During the discussion on the first day of the workshop as well as observations in the clinic, many non-value-added steps were identified. These included overprocessing/correction of paperwork at registration and wait times for registration, cast off, x-rays and seeing the provider. Transportation of patients from waiting room to provider room to x-ray and back was also identified as an issue. Also noted were inefficient use of space and resources, and problems with unclear directions and way-finding in the clinic. The wait times between each step of the process were viewed as wasted time from the patient/family perspective. Patient flow was identified as the area that provided the most problems and dissatisfaction for our patients, families, staff and providers. The weeklong workshop focused on ways to improve the patient flow process from check-in/registration to patient check-out.  The targets for improvement included decreasing patient wait time by 50 percent, casting lead time by 50 percent and x-ray lead time by 50 percent.
In the past, the orthopaedic practice operated as three separate clinics with three separate lobbies and check-in windows. It was decided to look at the entire orthopaedic clinic as one clinic or service line. In order to expedite patient check-in and registration flow, all patients were pre-registered and the daily charts were relocated to the back office. This decreased the amount of time the ambulatory service representatives (ASRs) had to be away from their desks when walking each patient chart to the back office. Workflow, processes and spaces were standardized so that work could be done more efficiently. A kiosk was added for all patients to check-in. (It was later noticed that a line formed at the kiosk and thus a second one was added, which decreased the wait time for check-in.) Once signed in, the patient/family is called to any of the four registration windows as the ASRs are available. In order to decrease transportation, as well as cast-off/x-ray lead times, a color-coded screen, known as the “patient tracker,” is pulled up on many of the computer screens, allowing staff to identify when a patient is ready to move to the next step. For example, each service is identified by a different color that alerts the staff when a patient is ready to move from the “cast-off” room to radiology or to a provider room. This improved communication greatly within the clinic as did utilizing cordless phones between the ASRs and orthopaedic technicians (OTs). Having to wait for an interpreter was another source of “wasted time” and lengthened the clinic visit. Electronic interpretive equipment was added and is utilized when an interpreter is not available.
The physical flow of the patients throughout the clinic was changed by sequencing the visit ahead of time, and by identifying the services needed and their order. For example, if the patient needed a cast-off and/or an x-ray he/she was routed first to a cast-off room and/or radiology, and then moved to a provider room. This decreased the amount of time the patient spent in one of the limited number of provider rooms. Patients were rerouted through one “intake” entrance into the clinical area and asked to check out through one of two exits. This helped expedite the check-out process whereas before there was only one window to check out and occasionally a line would form. The patients are led in the correct direction to check-out by following the blue tiles that were installed throughout the clinic. The waiting room was also painted to reflect one large lobby rather than separate areas.

As the above changes were made, “pulse surveys” were done for three days in December 2011 and February 2012. The surveys were done to assess patient/family satisfaction with wait times for each step of the process. In December, 76 families were surveyed and in February, 60 families were surveyed. Overall the satisfaction scores were very positive with the highest percentages in the good and excellent categories. It was noted that the satisfaction score of the wait in the exam room for the provider increased from 90 percent to 93 percent. Pulse surveys were also done during the same time period to document the timing of patient flow throughout the clinic visit. The total time of the visit was looked at from the time the patient registered until the patient checked out of the clinic. In general, the total time has decreased. Improvement has been noted and ongoing efforts continue.

It has been about 90 days since our LEAN workshop and we are entering Phase Two. The schedules are now being looked at to “level-load” which levels out the number of patients scheduled at any one time. The provider templates are currently being designed to balance the types and sequence of visits amongst the providers so not too many patients arrive at the same time in need of the same service, such as a cast removal. Schedules of patients are being balanced throughout the day between all providers. Once this is implemented in April, we anticipate the overall length of the clinic visit to drop significantly thus improving the satisfaction of patients, families, staff and providers.

The team continues to evaluate and make ongoing improvements to the process by meeting daily, weekly and monthly and performing audits. The meetings and task lists are directed by our supervisor, Martha Kroll. The LEAN process and Rapid Improvement workshops have been a valuable tool and may be utilized in any area of the Hospital. Once trained in LEAN, those processes can be applied in personal life as well. We were very fortunate to have been asked to participate in the workshop to benefit the orthopaedic practice at Children’s Hospital. The improvements could not have been made without the support of the Hospital administration and management team, the workshop team, and especially the positive attitudes and unwavering energy of the staff of the orthopaedic practice.  They are the ones to thank! 



James BrusenbackCauryn Evans

New Processes in the Achievement
of Patient Throughput in the
Emergency Department

By James Brusenback, BSN, RN, MICN and
Cauryn Evans, BSN, RN, CPEN, MICN


In spring 2011, emergency department (ED) and Hospital leadership recognized an ongoing need to enhance patient throughput in the ED. As a result, a consultant group (ECHO) was engaged to assist in identifying the EDs patient flow and other process weaknesses, and recommended concrete changes to enhance throughput. The main goals of the engagement included improving patient safety, improving patient throughput times, and improving patient satisfaction. Improved access to services for patients was identified as a potential important benefit of the project as was brainstorming optimal utilization and patient flow through the west expansion, the 11 new treatment rooms that would be available for use.

Initial teams were formed to analyze and challenge existing processes. Staff feedback was instrumental in designing the new patient flow and critical in gaining their trust and acceptance of the new flow model. Concurrently, ECHO provided data and analysis in the form of simulation modeling. As the teams worked through potential process and workflow changes, ECHO was able to provide guidance and direction into consideration of those changes that would create the greatest possible positive impact. ECHO provided multiple patient-flow scenarios to the ED leadership and work teams, which included assumptions based on a year’s worth of data to support the simulation modeling process.

The computerized simulation modeling methodology used for the project was a software product provided by the consultant. The method creates a computerized model of the current state for the purpose of evaluating the behaviors of various conditions or combinations of conditions. The model is created by using data from Hospital information systems, clinical observation, and observation and measurement of process interval times. Once a base case is created, the model allows the analyst to draw inferences and run multiple scenarios that perturb the base case.1 Running various scenarios allows testing of new processes, practices and systems without the need to make expensive and time-consuming changes to the existing state. The model allows the project team to ask “what if” questions, locate bottlenecks and compare alternate system designs. Applying multiple improvement strategies through the use of the model identifies optimized solutions to existing current state issues. ED leadership selected those strategies with the most significant outcomes in the simulation modeling. These were then implemented with subsequent training and monitoring of project metrics.

Although many changes and/or additions were considered, those implemented into the ED patient flow include the following:

  • Quick registration – Registration process allows for rapid identification and streaming of patients.
  • Implementation of the Emergency Severity Index (ESI) – In addition to assigning triage acuity, the ESI allows for consideration of needed clinical resources as well.
  • Total front-end patient loading accountability given to the patient flow coordinator (PFC) – The PFC assigns the ESI level and enforces the “any patient, any bed” ideology.
  • Change in the charge nurse role – Emphasis has shifted to pushing the patients through the department and ensuring timely discharge or admission. The charge nurse maintains constant communication with the PFC.
  • Patient throughput manager (PTM) support – The PTM provides needed support for ED patient flow initiatives.
  • Board Rounds – These rounds are attended by the PFC, PTM, charge nurse, and charge MD at regular intervals to ensure efficient patient flow and bed placements, identify bottlenecks, and/or brainstorm solutions.
  • Team Triage – Team triage provides an area specifically designed to manage rapid medical screening during periods of high patient volumes.

These changes helped return the ED and staff to the fundamental purpose of triage, which further eliminated bottlenecks in setting acuities. The department, via the PFC management of patient loading, was better able to guide patients in the appropriate direction based on their acuities and resource needs. The process for patient flow became much more standardized based on resources, and not on individual practice habits. Quality and consistency in the delivery of care quickly became two major benefits of the process changes.

During the first week of implementation, there was a dramatic decrease in door-to-provider times and patients leaving without being seen. A nearly empty waiting room around the clock despite high patient volumes was revealed, absolutely unheard of in many emergency rooms. This outcome, along with numerous compliments and positive comments from patients’ families, served as fuel for the entire team to own and accept the full implementation plan. The ED was able to build on these initial successes from the first week of implementation in order to achieve outstanding results.

Since the implementation of the ED Patient Throughput project in June 2011, there has been a 50 percent reduction (30 minutes) in the time interval from when the patient arrives until they are seen by the physician. The total decrease in “length of stay” (defined as arrival through discharge) for patients in the ED has been reduced by 37 percent (90 minutes). In addition, the percentage of patients who leave the ED without being seen or treated by the physician has decreased by 83 percent to less than 0.5 percent of all patients coming to the ED. The impact for the seven-month period from June 2011 through December 2011 is that over 700 patients were treated in lieu of departing without being seen (based on 40,000 visits for that time frame) as a result of this project. The impact on patient safety is immeasurable related to those patients who would have otherwise left without treatment, as the severity of their illness/injury is unknown. Finally, the reduction in the “arrival-to-doctor” interval means that patients who would have otherwise been waiting for long periods in the waiting room were treated in a much shorter time frame, thereby mitigating potential complications related to delays in treatment.

Outcomes Descriptors:

  • Reduced door-to-doctor times providing patients with quicker access to necessary therapy and diagnostics
  • Reduced the number of times our patient community chooses to leave before seeing a physician
  • Increased rapid determination of high-acuity patients with an emphasis on immediate rooming and medical screening
  • Overall acceptance of the “any patient, any bed” mentality
  • Physician ownership of seeing patients as fast as possible once they are roomed
  • Increased nursing accountability for the patient load and a sense of urgency for patient flow through the department
  • Changes accomplished without additional FTEs or increased nursing hours – RN cost per units of service (UOS) has remained at budget, and even below budget

Also, and possibly most importantly, patient/family satisfaction survey scores have skyrocketed and the frequent expression of appreciation is overwhelming. The following response encompasses the improvements, “Wonderful experience for my child, I almost cried because I was amazed how well we were treated.” This comment has become the norm for the ED. The correlating satisfaction for the ED team is now the precursor to “wanting more” relative to improving performance. The innovative approach and optimal outcomes are what make this a unique and valuable project.



1 Computerized Simulation Modeling Methodology, (n.d.). Retrieved February 2012, from Echo Consulting group website,

Patient/Family Recognition of Nursing Excellence in the ED

As part of the 2012 National Nurses Week at Children’s, we would like to celebrate the ongoing nursing excellence in the emergency department. Listed below are comments from recent patient satisfaction surveys.

The nurse my daughter had was wonderful. She showed genuine concerns for her.

Nurse was excellent, very personable, experienced – explained everything to us.
Excellent experience.

NURSES: Excellent care – she was experienced and related to us.

Thanks to Grant for listening to my concerns, helping me feel comfortable and for being friendly and smiling. Thanks to everyone that was taking care of our baby, Caleb.

The nurse was very caring and attended to our needs; she really had a great personality and was extremely nice. A+ nurse. This was our first visit and it was a great experience. I was recommended by a friend.

I would like to thank Riann for making me feel comfortable and safe.

We had a great nurse, John; he made my son feel comfortable about the IV.

I would like to thank RN Amy for listening to my concerns, for helping me feel comfortable and for being friendly and smiling. Thank you RN Amy for taking good care of me.

My child's nurse, once we were put in a room, was very kind and took her time to listen to me. She was also very gentle to my newborn and took
her time to explain the doctor’s orders. Thank you.

The nurse that served us was really good and helpful.

Nurse Melissa was wonderful. She took great care of my baby and provided privacy for me to breastfeed. Thank you. 

In This Issue

Professional Practice

Professional Values

Theoretical Framework

Professional Practice


Collaborative Relationships

Care Delivery


Research / Evidence-Based Practice

Professional Development

Reward and Recognition