Abstract

Jones C, Talbot L. Using Systems Engineering to Redesign our Triage Process for our Ambulatory Stream in A&E: Part 2. Model to Modify with a One-Day Test of Change. Journal of Improvement Science 2021: 76; 1-21.

In August 2020, Swansea Bay University Health Board commissioned a 6-month health care systems engineering (HCSE) programme to focus on A&E. Using the Agile framework, a series of six sprints, each of four weeks in duration were planned. Each sprint will focus in on a specific microsystem in the overall process that makes up the larger A&E mesosystem. The HCSE team applied the 6M Design® framework and, in the first sprint, started by mapping and measuring the A&E triage microsystem. The primary purpose of the first two sprints were to improve the safety of the A&E process by reducing the waiting time for triage to an acceptable and reliable level.

We used the eleGANTT® system to capture events in real-time; to verify the accuracy of the data contained in the existing patient flow dashboard; and to calculate an accurate triage process cycle time. This data was used to conduct a demand-load-capacity-activity (DLCA) analysis which highlighted a mismatch between the triage flow-capacity available and that needed to keep up with the rate of demand. Although this initial analysis served as a useful guide, it did not take account of the degree of variation within our A&E mesosystem.

This second essay tells the story of what we learned during the first modelling phase of the project and explains the steps that we took in validating our first stochastic flow model of the triage process. This model allowed us to explore the effect of variation within our system and was used to plan our first test of change. On Monday the 5th of October 2020 we made a designed intervention and observed the average lead time for booking in at reception to triage fall by 60% from 30 minutes to 12 minutes.

4N Chart; Accident and Emergency (A&E); Agile; Demand-Load-Capacity-Activity (DLCA); Flow Capacity; Flow Constraint; Gantt Chart; Health Care Systems Engineering (HCSE); Healthcare; Microsystem; Niggles; Poisson Process; Stochastic Model; Triage; Unscheduled Care