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Improving the �Performance in the �Non-Critical Zone of the �Emergency Department

Green Zone Improvement Committee

Department of Emergency Medicine

University Malaya Medical Centre

2016/2017

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Non-emergency cases
Overcrowding of patients
Redirects from clinics
Access blocks to wards
Complex / broad spectrum of illnesses
Challenges faced at triage counter
Dynamicity of illness during the course of waiting

WHAT ARE THE CHALLENGES FACED IN THE GREEN ZONE OR NON-CRITICAL ZONE?

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KEY PERFORMANCE INDEX (KPI)

Key Performance Index ( KPI ) following the

MTC ( Malaysian triage category)

THE PROBLEM :

KPI in non critical zone ED UMMC, not achieved since 2015 !

>70% of non critical zone patients should be seen within 90 minutes

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YEAR ZONES	2017	2018	2019 (till Aug)
RESUS	5517	5339	3488
AMC	19059	17790	11913
NCZ (Non-critical Zone or Green Zone)	49368	48304	31899

STATISTICS OF PATIENTS PRESENTING TO

THE EMERGENCY DEPARTMENT BETWEEN

JAN 2017 TO AUG 2019

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PERCENTAGE OF PATIENTS PER ZONE IN 2018

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KPI FROM JAN 2016- FEB 2017

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KPI FROM 2015 – Aug 2019

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Specific

To improve the performance at the Non Critical Zone of the Emergency Department.
To address the delay in waiting time.
To create awareness and provide better understanding to the public on the role of an Emergency Department.

Measurable

Regular monitoring of the key performance indicator (KPI) and review of the log sheets of Medial Officers.
A patient satisfaction survey was also conducted using the convenience sample method.

Achievable

Measures of improvement were implemented in a timely manner

Relevant

Achieving the KPI and improving patient satisfaction

Time Bound

Target time set & followed as per Gannt chart

S.M.A.R.T Goals

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01/12/2016	Dec 2016	Jan 2017	Feb 2017	Mar 2017
Data collection (implementation)
Data collection (implementation)
Analysis & interpretation
Analysis & interpretation
Strategy for change
Strategy for change
Data collection(post-implementation)
Data collection(post-implementation)
Evaluation of intervention
Evaluation of intervention

Planned progress

Actual progress

GANNT CHART

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�MEASURES OF IMPROVEMENT

Personal logbook for MOs/HOs of cases seen, which is reviewed along with daily KPI
Minimum patients seen per shift set at average of 20 patients per MO
Logbook in Green Zone for entry of problems faced in the zone during a shift
“Pink alert” on EMR when patient waiting time reaches 60min
“Pit stop” activation for patient review and repeat of vital signs once on pink alert
“Time of registration” to “time first seen” is the recorded waiting time for patients to be seen.
Only relevant investigations to be taken in Green Zone
Allocation of a shift leader in all shifts in the Green Zone
Alert during surge in the number of patients
Separating T3 and T4 categories at triage and informing patients triaged as such from triage counter
Identifying misappropriate triage & re-triaging
CME based on uptriaged cases & relevant topics

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Personal logbook for MOs/HOs of cases seen
Minimum patients seen per shift set at average of 20 patients per MO

�MEASURES OF IMPROVEMENT

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MANUAL PERSONAL PATIENT LOG

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�MEASURES OF IMPROVEMENT

3. Logbook in green zone for entry of problems faced in shift

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LOG BOOK TO DOCUMENT PROBLEMS FACED IN THE NCZ

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4. “Pink alert” for patients waiting > 60 min

�MEASURES OF IMPROVEMENT

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PINK ALERT

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5. “Pit stop”

Reassessment at pit stop by a healthcare provider

�MEASURES OF IMPROVEMENT

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�“PIT STOP” BAY SET UP IN GREEN ZONE

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6. “Time of registration” to “time first seen by a doctor ” is set as the recorded waiting time for patients to be seen

Previously – the waiting time commenced from the primary triage till the patient was first seen by a doctor.

Primary triage

Secondary triage

PREVIOUS Registration

CURRENT

Time first seen by doctor

�MEASURES OF IMPROVEMENT

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Instructions printed on the triage slip

�Measure to improve flow from primary triage �to registration counter

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7. Only relevant investigations are to be requested in Green Zone

�MEASURES OF IMPROVEMENT

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8. Appointment of a shift leader

�MEASURES OF IMPROVEMENT

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ROLE OF A SHIFT LEADER

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9. Alert during surge in the number of patients

�MEASURES OF IMPROVEMENT

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10. Separating T3 and T4 categories

�MEASURES OF IMPROVEMENT

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SEPARATION OF T3 AND T4 CATEGORIES

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11. Identifying misappropriate triage & re-triaging

12. CME for MAs – monthly

�MEASURES OF IMPROVEMENT

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UP-TRIAGE FORM

Copyright

ED Green Zone Committee

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�� PATIENTS UPGRADED FROM NON-CRITICAL ZONE FROM MARCH 2017 – DEC 2018 �

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Total number of patients upgraded

____________________________________ x 100% = % up triage

Total number of patients green zone

% of RED triaged GREEN (under-triaged) is = ≤ 0.5%

A KPI OF MOH GUIDELINE

(Ref : TECHNICAL SPECIFICATIONS FOR KEY PERFORMANCE INDICATORS (KPI) CLINICAL SERVICES MEDICAL PROGRAMME 2016)

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THE OUTCOME...

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KPI FROM 2017 – Aug 2019

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THE NEXT STEP…..

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��

An objective look at a patient’s experience from the start to the end of an ED visit IN THE NON CRITICAL ZONE
Overall satisfaction rating from the patients
Survey taken from 307 patients from Green Zone, over the months of May & June 2017
Cross sectional survey using convenience sampling method

PATIENT SATISFACTION SURVEY

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Survey form was constructed in English and Bahasa Melayu.
Components of the survey are based on 5 key factors

Facilities
Environment
System
Personnel
Treatment

( close-ended questions)

Survey forms were given randomly to the patients at the end of their consultation / treatment to be filled in.

PATIENT SATISFACTION SURVEY FORM

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SURVEY FORM

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TINJAUAN KEPUASAN PESAKIT

Sila jawab soalan-soalan berikut bagi membantu kami lebih memahami keperluandan pengalaman para pesakit semasa ke Jabatan Kecemasan UMMC. Sila tandakan pangkah(X) dalam kotak yang berkenaan.

KEMUDAHAN

1. Adakah anda memerlukan kerusi roda semase ke Jabatan Kecemasan?

◻ Ya (Sila ke no 2)

◻ Tidak (Sila ke no 3)

2. Adakah anda berpuas hati dengan kemudahan dan keadaan kerusi roda?

◻ Ya

◻ Tidak Sila pilih 1 sebab: ◻ Keadaan kerusi roda kurang memuaskan

◻ Kerusi roda tidak mencukupi

3. Adakah anda berpuas hati dengan lokasi tempat menurunkan pesakit menggunakan kenderaan persendirian di depan pintu Jabatan Kecemasan?

◻ Ya ◻ Tidak

PERSEKITARAN

4. Adakah anda mendapati ruang menunggu bersih dan rapi?

◻ Ya ◻ Tidak

5. Adakah anda mendapati papan-papan tanda di Jabatan Kecemasan jelas & mencukupi?

◻ Ya ◻ Tidak

SISTEM

6. Adakah anda dapat memahami laluan yang bermula dari kaunter Penyaringan ke kaunter Pendaftaran sehingga ke kawasan menunggu?

◻ Ya ◻ Tidak

7. Berapa lamakah anda menunggu untuk dipanggil oleh doktor? (“Malaysian Triage Category” mengklasifikasikan masa menunggu Zon Bebas-kritikal sebagai kurang dari 90 min)

◻ Kurang dari 30min (Sila ke no 9)

◻ 30- 90 min (Sila ke no 9)

◻ Lebih dari 90min (Sila ke no 8)

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8. Pada pendapat anda, adakah Zon tersebut sibuk pada masa itu?

◻ Ya ◻ Tidak

KAKITANGAN

9. Adakah anda puas hati dengan layanan atau rawatan daripada jururawat?

◻ Ya ◻ Tidak

10. Adakah anda berpuas hati dengan cara konsultasi doktor mengenai keadaan anda?

◻ Ya ◻ Tidak

RAWATAN

11. Adakah anda berpuashati dengan rawatan yang diterima?

◻ Ya ◻ Tidak

12. Adakah anda diberi arahan yang jelas untuk rawatan susulan, jika ada atau apa yang harus dilakukan jika keadaan anda tidak bertambah baik?

◻ Ya ◻ Tidak

Bagaimanakah keseluruhan pengalaman anda semasa anda di Zon bukan kritikal di Jabatan Kecemasan UMMC?

Sila tanda salah satu (1) daripada perkara-perkara berikut:

KURANG MEMUASKAN
MEMUASKAN
BAGUS
CEMERLANG

*********** TERIMA KASIH ***********

Implementation Date: 8/5/2017

An improvement activity by UMMC ED Green Zone Improvement Committee

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PATIENT SATISFACTION SURVEY

Please answer to the following question to help us to better understand your experience and needs during your visit to the Emergency Department of UMMC. Place a cross (X) in the corresponding boxes

FACILITIES

1. Did you require the use of a wheelchair?

◻ Yes (Proceed to no 2)

◻ No (Proceed to no 3)

2. Were you satisfied with the availability and the condition of the wheelchairs?

◻ Yes

◻ No Please pick 1 reason: ◻ In bad condition

◻ Insufficient in number

3. Was the location of patient drop-off point via personal vehicle at the entrance of the Emergency Department convenient?

◻ Yes ◻ No

ENVIRONMENT

4. Did you find the waiting area clean and presentable?

◻ Yes ◻ No

5. Did you find the signboards in the Emergency Department adequate & clear?

◻ Yes ◻ No

SYSTEM

6. Were you able to understand the flow of direction starting from the Triage counter, to the Registration counter & up until the waiting area?

◻ Yes ◻ No

7. How long did you wait to be called for initial consultation by the doctor? (The Malaysian Triage Category classifies the Non-critical Zone waiting time as < 90 min)

◻ Less than 30min (Proceed to no 9)

◻ 30- 90 min (Proceed to no 9)

◻ More than 90min (Proceed to no 8)

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8. From your observation, was it busy in that zone of the Emergency Department?

◻ Yes ◻ No

PERSONNEL

9. Did you find the staff nurses in attendance approachable and helpful?

◻ Yes ◻ No

10. Were you satisfied with the doctor’s examination & consultation of your medical condition?

◻ Yes ◻ No

TREATMENT

11. Were you satisfied with the treatment received?

◻ Yes ◻ No

12. Were you given clear instructions for follow up treatment, if any, or on what to do if your condition does not improve?

◻ Yes ◻ No

13. Please rate your overall experience during you visit to the Non-critical Zone of the UMMC Emergency Department today by ticking one (1) of the following:

POOR
SATISFACTORY
GOOD
EXCELLENT

************* THANK YOU *************

Implementation Date: 8/5/2017

An improvement activity by UMMC ED Green Zone Improvement Committee

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SURVEY RESULTS

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MOVING FORWARD…

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Inform the public on the role of Emergency Department
Increase awareness on critical vs non-critical cases
Educate patients eg. First aid measures, BLS
Inform the public on the locations of available KKM clinics within Klang Valley

PUBLIC EDUCATION & AWARENESS

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EXAMPLE OF PUBLIC EDUCATION POSTERS

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CUTS
DO’s	DON’T’s
Wash the cut thoroughly with water Use direct pressure to stop the bleeding: �- plaster for small cuts - clean cloth/ bandage for deep wounds with bleeding �- pressure AROUND the object causing a penetrating wound	Assume that a minor wound is clean because you can't see dirt or debris inside. Always wash it. Try to clean a major wound, especially after the bleeding is under control. Keep the cloth/ bandage on. Remove a long or deeply stuck object from the wound

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BURNS
DO’s	DON’T’s
If the skin is unbroken, run cool water over the area of the burn or soak it in a cool water bath (not ice water). Keep the area under water for at least 5 minutes Protect the burn from pressure and friction.	Apply ointment, butter, ice, medicines, cream, oil spray, or any household remedy to a major burn Disturb blistered or dead skin Remove clothing that is stuck to the skin Place a severe burn in cold water. This can cause shock�

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We succeeded in achieving the KPI
Patient care and safety were constantly a focus
The KPI achieved was maintained and sustainable
Relevant and timely
Zero costs incurred

CONCLUSION

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�

THANK YOU