SummarySwedish Medical Center implemented a new service request system in which physicians and staff requesting services must prioritize the order into one of four categories: "STAT" (needed turnaround time of 45 minutes or less), "ASAP" (45 minutes to 2 hours), "Routine" (8 hours or less), and "Timed" (orders that need to be filled within a specific time, ranging from immediately to several days). The four-category system applies to all hospital orders, including laboratory tests, requests for assistance from personnel, and facility repairs. The percentage of STAT requests fell significantly as a result of the new system.Moderate: The evidence consists of pre- and post-implementation comparisons of key measures, including the percentage of STAT orders.
Developing OrganizationsSwedish Medical Center
Date First Implemented2007
Problem AddressedBefore implementation of this new system, there was no standardized method for ordering services or tests within Swedish Medical Center facilities, which led to heavy reliance on STAT orders and slow turnaround times.
- High percentage of STAT orders: Most orders were requested STAT (i.e., for immediate fulfillment), as physicians and staff used the STAT designation as the default status, believing that non-STAT orders would endure long delays before completion.
- Inconsistent, slow turnaround: Turnaround times for orders were inconsistent and often slow (because higher emphasis was placed on unjustified STAT requests). Overreliance on the STAT designation led to a backlog of orders, which resulted in delays in orders that genuinely demanded urgency. Before the implementation of the new program, there were three choices for requests: STAT, ASAP, and Routine. There was no standardized definition for the terms, however, nor was a specific response time designated for choices. This resulted in the inability to meet anyone's expectations.
Description of the Innovative ActivitySwedish Medical Center's new system requires that those ordering services designate one of four priorities that vary according to the promised turnaround time (which is defined as the time interval between submission of the order and when the results are available). The four categories are described below:
- STAT (turnaround time of 45 minutes or less): This category is reserved for the highest priority orders, (i.e., life-threatening situations). Although STAT orders have a maximum turnaround time of 45 minutes, in many cases, they need to be fulfilled immediately or within a few minutes. Clinical examples of the appropriate use of the STAT designation include orders for patients with hemorrhages or allergic reactions, and glucose tests for a newborn. Nonclinical examples include maintenance staff coming to fix a burst pipe in a patient's room, or a sudden electrical outage in a patient room or unit. About 20 percent of orders are requested STAT.
- ASAP (45 minutes to 2 hours): ASAP (as soon as possible) designation is meant for situations that are not life-threatening but where completion of the order will have significant clinical or throughput implications. Examples include most orders for emergency department patients, such as computed tomography scans and many other laboratory tests (e.g., for strep throat). Nonclinical examples include a light malfunction in a patient room and patient discharge transports. The usual response time depends on the department and the situation, but most ASAP lab requests are returned within 1 hour.
- Routine (up to 8 hours): This category covers nonurgent orders that typically can be done as a standard part of a staff member's shift. Clinical examples include orders for nutrition consults and physical therapy. Nonclinical examples include installing/repairing nonelectronic medical record computer related problems and human resources issues with employees that are not threatening to the employee or the patient. About 30 to 50 percent of orders are designated as routine.
- Timed (scheduled): There are two types of timed orders:
- ASAP timed orders: ASAP timed orders are tests requiring results within 2 hours but they can be ordered in advance with a specific time for completion/results. Examples include partial thromboplastin time tests to adjust the dosage of heparin and glucose tests to adjust the dosage of insulin.
- Routine timed orders: Routine timed orders are tests without an immediate expectation for results or service. For example, a doctor might request a test on Monday specifying the result by a certain time and day, such as the following Thursday. Examples include laboratory tests to measure the level of specific drugs in the bloodstream and tests to assess the success of respiratory therapy treatments.
Context of the InnovationSwedish Medical Center includes three hospitals and a fourth facility with an emergency room and specialty services. Several factors led to the development of the new prioritized order system, including a growing realization that staff were requesting STAT orders in many nonurgent cases; Swedish Medical Center leaders' desire to increase the application of Toyota's Lean manufacturing principles that emphasize improved service delivery through elimination of inefficient processes; and the institution's impending conversion to an electronic medical records system that could easily be set up to require employees to choose from one of the four categories when placing orders.
ResultsComparisons of key metrics before implementation to results achieved 6 months after implementation show that the new ordering system reduced STAT orders, and length of stay (LOS) while increasing the percentage of orders filled on time.
Moderate: The evidence consists of pre- and post-implementation comparisons of key measures, including the percentage of STAT orders.
- Fewer STAT orders: Overall, the percentage of STAT orders fell significantly. The biggest decline was in medical imaging tests, where the percentage of STAT orders fell 50 percent. Other significant decreases included a reduction in laboratory STAT orders between 15 and 20 percent.
- Reduced LOS: Having results reported back in a quicker fashion was one of the elements that contributed to Swedish Medical Center's decreased LOS.
Planning and Development ProcessKey steps in the planning and development process include the following:
- Initial assessment: In March 2005, directors and managers of key departments began meeting monthly to assess the current situation and discuss the need for and desired attributes of an improved order system. Participants included representatives from administration, ancillary/support services, care management, emergency departments, information services, nursing, operational effectiveness, and the medical staff.
- Committee formation: The early meetings led to the formation of a three-person oversight committee consisting of the vice president of ancillary/support (who served as committee chair), the director of care management/care coordination, and a senior consultant from operational effectiveness.
- Creating the system: In subsequent meetings, committee discussions focused on creating the four categories and a user-friendly worksheet to facilitate ordering in each department. The committee also worked with department leaders to discuss how common tests should typically be categorized. For example, the committee and physician representatives discussed which laboratory tests genuinely need to be completed within an hour, and which tests can be completed within several hours without compromising patient safety.
- Gaining approval from key internal constituencies: The oversight committee finished developing the four-category system and the framework for its use in late 2006. The committee presented the new system to key hospital groups, committees, and individuals for their approval (e.g., physician leaders, nursing department leaders, the quality management committee, the medical executive committee, clinical information system staff).
- Training and education: Several tactics were used to show staff how to use the new order system, as described below:
- Small group sessions: Staff attended training sessions in small groups (e.g., nurses, physicians, lab staff). For staff who frequently place orders, training emphasized the importance of requesting orders STAT only in life-threatening situations; for staff who fill orders, training focused on the importance of completing orders on time (regardless of the category).
- Written educational materials: Staff received a pocket card with brief definitions and examples of each category, as well as department-specific handouts with common examples in each category. In addition, brochures, flyers, posters, and memos describing the system were distributed at meetings, and posted on Swedish's internal Web site. Some of this material was tailored to specific audiences, such as nurses, emergency room staff, and support staff.
- Additional training for nurses: Because nurses often place orders on doctors' behalf, they received additional training on handling common challenges, such as how to respond when doctors unnecessarily request orders STAT and what to do when orders are not filled on time.
- New hire training: Information on the order system was incorporated into the orientation process for new hires.
- Program rollout: The new system was implemented throughout the hospital system in April 2007. In April 2008, the new order system switched to a new electronic medical record system (known as Epic®).
Resources Used and Skills Needed
- Staffing: The new order system did not require additional staffing. The members of the oversight committee, department leaders, and employees implemented the system as part of their regular jobs.
- Costs: The costs to implement the program included meeting times for planning and implementing as well as costs to produce materials. Costs are estimated at approximately $20,000.
Funding SourcesSwedish Medical Center
The costs of developing and implementing the new order system was covered by Swedish Medical Center's internal operating budget.
Getting Started with This Innovation
- Include key constituencies in the planning and development process: Physician and nursing leaders and representatives from other key departments should be involved in the planning and development process for the new system because their support is critical to successful implementation.
- Prepare to encounter and overcome doubts about credibility: The chief obstacle to successfully implementing this type of order system is employee and physician skepticism that orders will be filled on time. Such doubts often arise from prior experience. For example, a physician who needs a laboratory test result in 2 hours may request it STAT, believing this approach is the best (and perhaps only) way to ensure timely results. For physicians to abandon this mindset, they need to be sure that ASAP orders will be filled in less than 2 hours. Overcoming this skepticism is a gradual process; program leaders at Swedish Medical Center spent significant time and effort explaining how the new system would work, and then, once implemented, had to show that it worked as promised.
- Do not rush the rollout: Swedish Medical Center began planning in March of 2005 and officially launched the program in April of 2007. A lot of time was spent on educating physicians, nurses, and staff because it is critical to take the time to explain how the system will work and address any questions or concerns. Nurses should be among the first groups to be introduced to the system because their support is especially critical.
Sustaining This Innovation
- Track program results to identify and correct problems: It is important to continually monitor key metrics that gauge the impact of the program. For example, monthly reports cannot only evaluate the program's impact on STAT orders, turnaround time, and costs, but also reveal which departments have unusually high percentages of STAT orders, and which departments are not filling orders on time. Once identified, problem areas can be addressed through additional training and, if necessary, one-on-one meetings.
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Original publication: July 21, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 28, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: August 08, 2011.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.