McKahan's example was St. Vincent Health System in Little Rock, Arkansas, which used a linear plan. It has a 'thermometer' concept where units load up from one end to the next. It's has two levels for ambulance access as well as dedicated elevators; 18-foot wide staff core; 7-foot long perimeter corridor with no stretchers in that area; 145-gross-square-foot exam rooms; two seclusion rooms; bedside registration; a subwaiting area for test results; and an unobstructed line of sight down the perimeter corridor.

 

McKahan revealed some of the lessons learned on this project. The thermometer concept did not work as well as they hoped: ED staff had to walk longer distances and due to the positioning of the staff core, there was no daylighting. He suggested placing stations in the middle of the unit to reduce walking distances, linking the beds to the staff core, and allowing for a middle waiting area.

 

Texas Health Harris Methodist, with The Stichler Group as the lead architect, designed their ED with a focus on the patients. There is a pod system with small exam rooms, triage is now behind the scenes, and trauma pods with open access to supplies. Hamilton quoted a member of the medical staff who stated that "A sign-in sheet is a sign of disfunctionality." The ED aimed to remove the concept of a waiting room. 

 

The hospital is looking to learn from their design by enhancing care for patients with three care levels—each with its own dedicated staff, use scribes to increase efficiency, and overlap the doctors' responsibilities within a shift to avoid information gaps. Hamilton also pointed out the need for consistent leadership from innovation champions within the organization. 

 

St. Clair Hospital in Pittsburgh applied Lean operations to their ED planning. There was, initially, a lack of standardization and a problem with inpatient throughput. Zilm states that by applying Lean principles, 'Kaizen', and rapid-cycle testing the ED was able to see improved results. They shifted to a zone/team model, eliminated traditional triage except when at capacity, and designed a mock-up room. The large exam rooms (130 - 240 square feet), in a pod-ized layout, were designed to be as efficient as possible so that staff could reach for what they needed instead of walking. These design and application changes lead to first place recognition by Press Ganey in 2010.

 

Zilm also provided some facts on Hershey Medical Center's ED improvements. 

- PDQ provider-directed process;

- patients seen as soon as they arrive (mini registration, nurse performs quick triage);

- Press Ganey score rose to 17%; and

- minimal waiting at the front end. 

An interior waiting area allows patients to await their test results and process their copays with a cashier in a quiet environment.