The Need to Address Emergency Department Crowding
Emergency departments (EDs) nationwide are experiencing significant overcrowding, with nearly 50% operating at or above capacity A staggering 90% of hospitals report boarding admitted patients in the ED while they wait for inpatient beds, leading to the diversion of approximately 500,000 ambulances annually from the nearest hospital This persistent issue of ED crowding has garnered extensive media coverage, legal actions, and research investigations.
Addressing emergency department (ED) crowding should be a top priority for hospital and ED leaders due to its significant impact on overall hospital performance and patient care Prioritizing this issue can lead to improved patient outcomes, enhanced operational efficiency, and increased satisfaction for both patients and staff.
1 ED Crowding Compromises Care Quality
Emergency departments (EDs) operate in high-risk, high-stress environments where exceeding capacity increases the likelihood of errors The six dimensions of quality outlined by the Institute of Medicine (IOM)—safety, effectiveness, patient-centeredness, efficiency, timeliness, and equity—can be jeopardized when patients face long wait times, are boarded in the ED, or when ambulances are redirected from the nearest hospital Recent studies have provided compelling evidence supporting these concerns.
ED crowding contributes to poor quality care 1-5
In 2007, 1.9 million individuals, or 2 percent of all emergency department (ED) visits, left without being seen, primarily due to long wait times, resulting in significant revenue loss for hospitals A 2006 study indicated that each hour of ambulance diversion led to a loss of $1,086 in hospital revenue Furthermore, a recent study revealed that reducing ED boarding time by just one hour could generate over $9,000 in additional revenue by decreasing both ambulance diversions and the number of patients leaving without care Additionally, a crowded ED hampers an institution's ability to accept referrals and raises medicolegal risks.
3 Hospitals Will Soon Report ED Crowding Measures to CMS
The Centers for Medicare & Medicaid Services (CMS) has introduced five measures related to emergency department (ED) crowding as part of the Hospital Inpatient Quality Reporting Program These measures include the patient median time from ED arrival to departure for discharged patients and the door-to-diagnostic evaluation by a qualified medical professional, both assessed for calendar year 2013 Additionally, the program tracks the number of patients who left before being seen, as well as the median time from ED arrival to departure for admitted patients and the median time from admit decision to departure for admitted patients, both evaluated for fiscal year 2014.
5 a Hospital Inpatient Quality Reporting Program Overview available at www.qualitynet.org.
Hospitals must report specific measures to the Centers for Medicare & Medicaid Services (CMS) to qualify for the complete Medicare payment update These measures, endorsed by the National Quality Forum in 2008, are widely utilized by researchers to evaluate changes in emergency department (ED) crowding and patient throughput Ultimately, this data will be made available to the public.
4 ED Crowding Compromises Community Trust
The Emergency Department (ED) is essential to the community, expected to deliver timely care around the clock and manage public health emergencies Physicians often refer patients to the ED for after-hours convenience, complex cases, liability issues, and necessary diagnostic tests unavailable in their offices Due to high patient volumes, the ED often serves as the public's primary interaction with healthcare organizations However, crowding can result in long wait times and hinder patient privacy and care, potentially undermining community trust in the healthcare system.
5 ED Crowding Can Be Mitigated by Improving Patient Flow
In recent years, significant efforts have focused on identifying the causes of emergency department (ED) crowding and exploring effective solutions There is a consensus that enhancing patient flow within the ED and across the hospital can effectively mitigate crowding issues Several hospitals have successfully implemented strategies to improve patient flow, leading to measurable reductions in ED crowding Consequently, various organizations, including the Institute for Healthcare Improvement, the Joint Commission, and the Institute of Medicine, have urged hospital leaders to embrace these patient flow improvements.
This guide offers a comprehensive, step-by-step approach to enhancing patient flow in hospitals, featuring real-world examples of successful implementations, challenges faced, and effective solutions It is designed for a diverse audience, including hospital CEOs, quality officers, risk managers, emergency department directors, clinicians, and staff, all aimed at alleviating emergency department crowding.
This guide compiles insights from hospitals affiliated with Urgent Matters, a national initiative funded by the Robert Wood Johnson Foundation aimed at enhancing patient flow and alleviating emergency department (ED) crowding Since its inception in 2002, Urgent Matters has established a learning network with 10 hospitals, fostering collaboration and providing technical support to implement best practices for managing ED congestion The outcomes of these efforts are detailed in the report titled "Bursting at the Seams: Improving Patient Flow."
In 2008, Urgent Matters initiated a second learning network involving six hospitals, which included a formal evaluation of patient flow improvement strategies This evaluation assessed the facilitators and barriers to implementation, as well as the associated time and expenses, and the overall impact of the strategies The findings are detailed in the report titled "Improving Patient Flow and Reducing ED Crowding: Evaluation of Strategies from the Urgent Matters Learning Network II."
Forming a Patient Flow Team
Research highlights the significance of forming multidisciplinary teams for effective quality improvement interventions These teams offer diverse perspectives and expertise, which enhance the understanding of problems, their root causes, and potential solutions.
Identifying the right individuals to participate in implementing patient flow improvement strategies is crucial for success Team members can provide valuable resources and foster support for solutions among their peers To ensure effective planning and implementation, the team should convene regularly, such as on a weekly basis.
To optimize your team structure, we recommend including a day-to-day team leader, a senior hospital leader such as the chief quality officer, technical experts relevant to your strategy, emergency department (ED) physicians and nurses, ED support staff like clerks and registrars, a research/data analyst, and representatives from inpatient units.
The UMLN participants emphasized the crucial roles of registrars, clerks, technicians, and other support personnel in successfully implementing strategies, highlighting the necessity of including them in planning processes Additionally, they underscored the significance of securing explicit support from the chief executive officer (CEO), noting that while the CEO may not need to lead the system, their verbal endorsement and allocation of resources convey the importance of the strategy to the entire organization.
As you assemble your team, we recommend that you consider these questions:
1 Who will lead your team?
The Institute for Healthcare Improvement emphasizes the importance of having three key leaders in quality improvement teams: a day-to-day leader, a senior hospital leader, and a technical leader The day-to-day leader plays a crucial role in ensuring timely task completion and motivating the team through challenges This leader is also tasked with communicating the strategy to both the team and external stakeholders, requiring adequate time commitment to the improvement strategy It is essential for the day-to-day leader to possess strong collaboration skills and the authority to ensure their requests are respected.
Senior hospital leaders, such as the chief nursing officer and chief quality officer, possess the necessary authority to address challenges that may arise They understand the impact of quality improvement initiatives on the organization and its various departments.
Importantly, the system leader should be someone who can assist with the acquisition of resources to support the strategy, as needed
A technical leader provides essential technical support and guidance to the team, particularly when implementing changes, such as modifying forms in electronic medical records This role often requires collaboration with IT experts to ensure successful execution Additionally, a technical leader possesses a deep understanding of care processes within the organization, facilitating effective strategy development and implementation.
To enhance the flow within the fast track, it is essential to have a fast track nurse who comprehensively understands the patient journey from admission to discharge Additionally, teams may benefit from having multiple technical leaders, including one focused on care processes and another specializing in data abstraction and analysis.
Example 1 Team Leadership at Hahnemann University Hospital
The patient flow improvement team at Hahnemann University Hospital in Philadelphia implemented the five-level Emergency Severity Index (ESI) triage system as part of their UMLN II participation The ED assistant director led the initiative, forming a team that included the chief nursing officer, an experienced ED physician, a nurse educator, and seven additional ED nurses These nurses were strategically chosen for their openness to change and leadership qualities, facilitating effective communication and implementation of the ESI among the nursing staff.
Note: Emergency Severity Index: Version 4 Rockville, MD: Agency for Healthcare Research and Quality; May 2005 Available at http://www.ahrq.gov/research/esi/
2 Which departments will be affected by your strategy?
Which departments need to participate in order for your strategy to be successful?
ED crowding is a multifaceted issue that affects the entire hospital, necessitating collaboration beyond the emergency department (ED) While some throughput strategies, like the implementation of the Emergency Severity Index (ESI), may focus solely on ED processes, more intricate patient flow strategies require input from various departments Successful implementation hinges on early involvement of representatives from these departments, as many ED teams have found that they cannot achieve their goals in isolation By expanding the team to include diverse departmental perspectives, the ED can benefit from innovative ideas and solutions that may not have been considered otherwise.
Example 2 A Hospital-Wide Strategy at Stony Brook University Medical Center
The patient flow improvement team at Stony Brook University Medical Center in Stony Brook, NY, developed a strategy to expedite specialty consultant requests Comprising mainly ED staff, the team set clear expectations for consulting physicians to respond within 30 minutes and complete the consult within 120 minutes ED clerks were tasked with monitoring these response and completion times.
The initial exclusion of consulting physicians from the planning process led to resistance against changes; however, once the patient flow team shared data on response times, service department chairs acknowledged the potential for improvement They emphasized the importance of achieving the 30- and 120-minute goals to their staff, which proved essential in gaining support for the new processes The chairs consistently reinforced that compliance was mandatory, highlighting the need for vigilant leadership to ensure adherence to the updated protocols.
3 Who will be a champion for your strategy? Who will oppose it?
Successful quality improvement initiatives hinge on staff commitment and engagement Research indicates that employees are more likely to embrace change when they participate in crafting solutions and can express their concerns A collaborative approach to enhancing patient flow allows team members to advocate for the initiative among their peers Additionally, including those resistant to change can provide valuable insights that enhance the improvement strategy, making it more appealing to the entire staff.
Example 3 An Inclusive Approach to Improvement at Westmoreland Hospital
There was general agreement that ED crowding and boarding at Westmoreland Hospital in Greensburg,
Inadequate communication between inpatient units and the emergency department (ED) has led to a lack of collaboration, with departments operating in isolation Previous attempts to enhance communication between the ED and inpatient units have been unsuccessful due to insufficient input from inpatient floors and resistance to proposed communication tools.
To address communication barriers, the team involved inpatient managers and staff early in the design of a new Inpatient Report Tool, a standardized one-page summary intended for faxing from the ED to inpatient floors before the patient's chart arrives Although this collaborative approach extended the planning timeline, it enabled the identification and resolution of potential issues upfront For instance, nurses in the progressive care unit raised concerns about the tool's lack of detail for their patients, prompting the patient flow team to collaborate with the IT department to develop an electronic version tailored for patients with more complex care needs.
Measuring Emergency Department Performance
Managing variation is crucial as it underlies all quality issues in both mechanical production and service industries Hospitals, embodying characteristics of both sectors, face unique challenges in minimizing variation in patient care By focusing on high-reliability production, hospitals can reduce waste and risk, while delivering excellent service fosters patient loyalty and enhances engagement among physicians and nurses.
Measurement is the most fundamental tool in the hospital leader’s toolkit to identify and mitigate variation.
Performance measurement serves as a crucial feedback mechanism for assessing the performance of healthcare services and production units Historically, hospitals have relied on financial data for analysis and decision-making, but there is an increasing need to gather quality data to meet the demands of various internal and external stakeholders Key areas of focus for measurement include regulatory and accreditation requirements, such as the core measures mandated by the Centers for Medicare & Medicaid Services (CMS), which emphasize timely interventions like administering fibrinolytic therapy within 30 minutes.
Hospitals must document compliance with Joint Commission standards, including data on ED arrival and aspirin administration In addition to financial metrics, strategic plans should encompass department-specific quality improvement goals and data necessary for credentials like Stroke Certification or awards such as Baldrige and AHA NOVA Participation in benchmarking projects allows hospitals to compare their performance with similar organizations The Rapid Cycle Change approach involves collecting project-specific data during the Plan-Do-Study-Act (PDSA) process to evaluate small-scale improvements, with measurements typically taken at the unit level by the care staff This short-term data collection is crucial for effectively achieving and sustaining process improvements Further details on PDSA will be discussed in the next section.
Measurement starts with a question and progresses to data collection, which involves three key steps essential for gathering data that offers valuable feedback to clinicians and stakeholders.
Clinicians face unique challenges in data generation, which encompasses the processes for entering information into medical records or management systems It is crucial for clinicians to understand the definitions of the data elements they record and the reasons for collecting this information To maintain clinician cooperation and ensure data accuracy, documentation should be straightforward Implementing periodic surveillance and audits, stratified by provider, can help guarantee the creation of accurate data.
The second phase of data abstraction involves harvesting data from the system, which can be resource-intensive, especially for organizations with limited data capabilities Over a third of U.S emergency departments still rely solely on paper records, and interoperability issues persist among hospital computer systems While data from billing or coding systems are typically found in consistent locations, clinical process data may be scattered throughout medical records, leading to increased staff time and training costs Successful abstraction often requires interdepartmental cooperation to create coordinated workflows Finally, the abstraction process should include validation through systematic random spot checks by a second abstractor to ensure data accuracy.
The third and final phase is data reporting Key decisions include how much to report and to whom.
This is a strategic planning decision that needs to align with the administrative, departmental, and unit goals
As hospitals transition to comprehensive quality data reporting, they recognize the distinction between financial and quality data collection Unlike the limited personnel involved in financial data, quality data reporting engages the entire hospital Front-line staff are crucial in identifying and addressing variations that lead to quality issues Consequently, hospital leaders must foster an environment where care teams actively identify, measure, and report key process variables, while also implementing necessary improvements This shift may necessitate changes in structure and culture regarding authority To navigate the complexities and uncertainties of modern healthcare, quality improvement must evolve from a departmental function to a fundamental mindset and practice.
Regulatory/Accreditation Mission Driven Rapid Cycle Change
Several existing measures impact the emergency department (ED), with additional measures set to influence hospital payments starting in 2012 These new measures will be featured on Medicare’s Hospital Compare website, similar to the core measures already available.
Figure 2 Pending emergency department measures
12 b Centers for Medicare & Medicaid Services Hospital Compare Web site Available at http;//hospitalcompare.hhs.gov.
Use of Brain Computed Tomography (CT) in the Emergency Department (ED) 2012 for Atraumatic Headache
Head CT Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients 2013
Who Received Head CT Scan Interpretation Within 45 minutes of Arrival
Troponin Results for ED Acute Myocardial Infarction (AMI) Patients or Chest 2013
Pain Patients (with Probable Cardiac Chest Pain) Received Within
Median Time to Pain Management for Long Bone Fracture 2013
Patient Left Before Being Seen 2013
Door to Diagnostic Evaluation by a Qualified Medical Professional 2013
Median Time from ED Arrival to ED Departure for Discharged ED Patients 2013
Median Time from ED Arrival to ED Departure for Admitted ED Patients 2014
Admit Decision Time to ED Departure Time for Admitted Patients 2014
Previous CMS ED measures related primarily to clinical processes (fibrinolytic therapy received within
CMS is expanding its focus on emergency department (ED) processes by incorporating throughput measures, such as the time from arrival to departure for both admitted and discharged patients, as well as the decision to admit and door-to-diagnostic evaluation times This shift aims to provide a comprehensive view of the ED experience, emphasizing the importance of collaboration among various hospital departments Despite criticism regarding the inclusion of "nonclinical" measures, CMS argues that these metrics reflect the overall efficiency of ED operations A year-long field test conducted by UMLN II hospitals demonstrated the practicality of tracking these measures, with staff interviews revealing insights into the advantages and challenges of this reporting process.
Initially, staff found it challenging to collect the measures, but they quickly adapted as the learning curve flattened The primary obstacle was the need to navigate multiple IT systems Surprisingly, staff did not foresee the necessity to hire additional personnel or provide extra training for the permanent implementation of the measures In fact, one staff member only required a brief phone call to learn how to access the nursing documentation system Overall, there was strong support among staff for the measures.
An ED medical director said the throughput measures were like “barometers” because they gave a global view of ED performance, while other, narrower measures, such as Door to Doctor, were
“yardsticks” yielding more specific information
An ED nurse shared that their facility set a throughput target of 150 minutes for discharged patients based on observations of patient dissatisfaction after that time frame, although he acknowledged this method was not ideal Staff members noted that having access to data enhanced their credibility when collaborating with other departments and fostered a culture of continuous quality improvement within the emergency department Crucially, this information empowered the staff to advocate for hospital-wide solutions to address ED crowding, emphasizing that it is a systemic issue rather than solely an ED concern.
Identifying Strategies
After establishing a patient flow improvement team and gathering performance data, hospitals must identify effective strategies to alleviate emergency department (ED) crowding and enhance patient flow Choosing the appropriate strategy is crucial for the success of any intervention By investing time in careful strategy selection, hospitals can prevent significant adjustments later, ultimately saving time and resources This section will guide you through the strategy selection process.
1 Identify the Most Likely Causes of the Specific Problems You Face
To enhance patient flow in the emergency department (ED) and hospital, your improvement team must identify potential roadblocks, such as lab turnaround times and delays in specialist consultations Utilizing performance improvement methodologies like Lean and Six Sigma, along with tools such as process mapping, can help pinpoint specific causes of these blockages Additionally, analyzing hospital data can reveal significant obstacles to patient flow By identifying these key roadblocks, your team can effectively direct its improvement efforts.
Example 4 Good Samaritan Hospital: Using Data to Aid Strategy Selection
Good Samaritan Hospital in Long Island, NY, reported a left-without-being-seen (LWBS) rate close to the national average of 2 percent Analysis revealed that 87 percent of LWBS patients were classified as Emergency Severity Index (ESI) Level 3, with the highest LWBS rates among those presenting with abdominal pain, flank pain, headache, pregnancy complications, vaginal bleeding, or vomiting, averaging 12.5 percent Additionally, this group of ESI 3 patients experienced an average length of stay of 426 minutes, significantly longer than the 294 minutes for all emergency department patients.
Patients with the highest left without being seen (LWBS) rates also experienced the longest physician wait times, with a median of 78 minutes compared to 48 minutes for all ESI 3 patients This issue arises because these patients have complaints that are too complex for fast track treatment but not severe enough for direct admission to the emergency department (ED) The risk of these conditions becoming life-threatening during the wait poses significant concerns for patient safety and quality of care.
To tackle the identified issue, Good Samaritan has initiated a strategy that promptly directs a specific group of ESI 3 patients to a dedicated physician and nurse practitioner After an evaluation by the physician during triage, these patients are attended to by a nurse practitioner who collaborates with the triage physician to coordinate their care effectively.
2 Explore What Other Hospitals Have Done to Improve Patient Flow
Many online resources outline successful strategies implemented by hospitals to enhance patient flow, which can inspire your team to develop effective solutions.
Setting realistic expectations for your strategy is crucial for success It's important to assess how ambitious your goals can be while remaining achievable Often, limited human and financial resources, such as capital and education, hinder the implementation of potentially effective strategies For instance, hospitals with access to additional staffing or full-time equivalents (FTEs) can pursue strategies that introduce new roles.
Hospitals with access to educational funds may be able to adopt strategies that are facilitated by current staff with enhanced skills
Securing leadership support is crucial for obtaining additional resources, as it is often the most valuable asset Without an administrative champion, acquiring necessary funding can be challenging Hospital leaders may be inclined to provide financial backing if you can demonstrate that your strategy will enhance patient revenue by decreasing the number of patients who leave without being seen and reducing ambulance diversion hours.
Leadership support is crucial for implementing changes that affect units and staff beyond the Emergency Department (ED) Without strong leadership backing, it is advisable for teams to concentrate on process improvements within the ED, as these typically demand minimal funding and do not necessitate collaboration with non-ED personnel.
Example 5 St Francis Hospital: Educational Resources Needed for Ambitious Strategy 15
St Francis Hospital in Indianapolis, IN, recognized the potential for front-end improvements due to effective nursing leadership and successful Lean Six Sigma initiatives In January 2009, the emergency department leadership at the hospital's south campus chose to implement quick registration and rapid triage strategies as part of the Urgent Matters Learning Network.
In late spring 2009, two nursing educators established an education subcommittee tasked with creating an educational plan to implement process changes This comprehensive plan encompassed various training methods, including presentations at staff meetings, one-on-one education, online training, huddles, emails, and educational folders.
In August and September 2009, presentations highlighted the educational folders, reported that 75 percent of nurses participated in at least one educational session, and reviewed the new triage process.
In early 2009, the ED director and a nurse leader underwent train-the-trainer training in a standardized triage methodology, which led to the training of ED staff nurses By the end of 2010, most registered nurses completed the two-day training and passed the certification exam This in-house training standardized both the mechanical and cognitive aspects of the triage process, incorporating rapid and comprehensive triage training The total training costs amounted to $7,000 for an additional trainer and $80 per nurse for on-site training.
Through UMLN II, we identified various processes hospitals can employ to select a strategy, which can range from individual decision-making to collaborative efforts by a performance improvement team This team can brainstorm and test multiple strategies through methods like kaizen events or rapid cycle changes before reaching a final decision Generally, the strategy selection process falls into one of two main categories.
UMLN II hospitals exhibited varied strategies in their approach to strategy selection, with some adopting a top-down method involving the ED leadership team and hospital leadership, while others favored a bottom-up approach driven by performance improvement methodologies like Lean.
Example 6 Thomas Jefferson Hospital: Selecting a Strategy Through the Ballot Box
Preparing to Launch
After selecting a strategy, it's essential to create a roadmap for implementation The team should develop an implementation plan (IP) to outline goals, resources, budget, and performance measures, with a template available in Appendix B The IP consists of four key steps, each detailed further below.
3 Estimate the time and expenses associated with implementation.
After finalizing the implementation plan (IP), it is essential to share it with hospital and department leaders to keep them informed about the ongoing efforts, including the timeline, budget, and required resources Regular updates to the IP may be necessary as new team members join or additional resources are identified; however, it is crucial to retain the original IP for the team to periodically assess progress against the initial budget and timeline.
This section provides instructions on completing the IP Appendix C presents an example of a completed IP
Step 1 Identify Goals and Strategies
In the initial section of the improvement plan, your team will articulate the problem statement, which should succinctly outline the existing practices that require modification and their negative effects on patient flow It is essential to include measurable aspects of the issue, such as, "The department lacks a valid and reliable triage system, resulting in 10 percent of patients initially triaged for fast track later needing a higher level of care," or "Inadequate inpatient capacity leads to an average hold time of 10 hours for admitted patients in the emergency department."
Your team should create a concise goal statement that specifies the process to be improved and includes a measurable criterion for success For instance, "Specialty physician service consultations will begin within 30 minutes of request, aiming to decrease the length of stay by 25 percent for patients needing consultations." The goal must be pertinent to patient flow, achievable, and quantifiable A goal like "reducing lab turnaround times by 50 percent" should only be chosen if your team has access to relevant data on those turnaround times.
The strategy description must outline the process that requires modification, ensuring it includes enough detail and is articulated in clear, straightforward language This approach will make it accessible to individuals across different departments, including those without clinical expertise.
The implementation plan's next section details the process of change and assigns responsibilities First, compile a list of project team members, including their titles and departments Next, identify potential barriers to successful implementation, such as issues with current processes or organizational culture, and refer to the "Facilitating Change, Anticipating Challenges" section for insights on common obstacles faced by patient flow teams Recognizing these barriers early allows for their mitigation to be integrated into the work plan and timeline, and may highlight the need for additional team members or resources Finally, adopt a formal improvement method, such as the Plan-Do-Study-Act (PDSA) process, widely used in healthcare This iterative cycle involves planning the change, testing it on a small scale, analyzing the results, and making necessary adjustments before full-scale implementation Repeating the PDSA cycle enables the team to refine the change until it is ready for broader application.
Testing changes on a small scale, such as during a single shift, offers numerous benefits It allows for quick implementation with minimal resource investment, providing insights into potential outcomes of full-scale changes Additionally, staff are often more receptive to testing modifications when they know adjustments will be made based on feedback.
Still, there are several other quality improvement approaches to use, such as Lean or Six Sigma, and many of these popular quality improvement approaches employ similar techniques Appendix
The implementation plan (IP) should detail the necessary steps for executing the strategy, including key milestones or "gates" that must be achieved Each step should incorporate PDSA (Plan-Do-Study-Act) tests of change to guide progress toward the next milestone As multiple PDSA iterations occur, additional milestones may emerge, necessitating adjustments to the timeline These implementation steps are crucial to the IP, highlighting the dynamic nature of quality improvement within the complex environment of a hospital.
As you progress through each step, it's essential for your team to designate a responsible individual for each task and establish a deadline for completion When drafting this section of the Implementation Plan (IP), keep in mind the following key questions.
– What data need to be collected?
– Do staff members need to be trained?
– Do forms (electronic/paper) need to be developed?
– Do purchases need to be made?
Example 7 Lean as a Method of Improvement
In 2008, Thomas Jefferson University Hospital in Philadelphia, PA, hired a new chief operating officer who saw a need to provide Jefferson staff with resources to improve performance He arranged for General
General Electric (GE) is training 45 employees in Lean and Six Sigma methodologies, enabling them to serve as facilitators for departmental improvements These trained facilitators are tasked with leading Lean-driven initiatives Subsequently, the patient flow improvement team at Jefferson applied Lean techniques to enhance efficiency in the emergency department's fast track.
Lean-trained facilitators conducted interviews with fast track and emergency department (ED) staff, observing work processes and documenting task completion times They found that the fast track nurse practitioner (NP) dedicated less than 40 percent of her time to NP tasks, while the nurse spent under 6 percent on nursing tasks Additionally, the facilitators identified significant sources of waste, such as nurses spending excessive time searching for equipment and supplies.
Next, the patient flow team participated in a 3-1/2-day kaizen (i.e., continuous quality improvement) event.
The team dedicated the first two days to observing and mapping the value stream of tasks from patient arrival to discharge in the fast track They identified both value-added and non-value-added tasks, concluding that a 90-minute turnaround time for patients could be achieved by implementing several key changes These included assigning a dedicated nurse practitioner, nurse, and technician to the fast track, even during peak times in the main ED, and posting a welcome sign to guide patients to registration Additionally, a technician was designated as a greeter to quickly identify fast track patients, while all fast track computers were equipped to print discharge instructions The nursing staff received training on Emergency Severity Index (ESI) triage procedures to better identify mid-acuity patients for the main ED, and supplies were continuously stocked Finally, the fast track was relocated closer to the front of the ED for improved accessibility.
In the final day-and-a-half of the kaizen event, the team executed the proposed changes, excluding the relocation of the fast track area, as a trial There was significant enthusiasm from the kaizen team, fast track staff, and ED leadership regarding these changes; however, ongoing efforts were necessary to ensure their sustainability Key follow-up tasks included ordering a permanent welcome sign for the waiting room, planning ESI education and competency assessments for triage nurses, creating written guidance on the roles of the NP, nurse, and technician in fast track, and organizing the fast track supply cart The team convened weekly for a month post-kaizen to review progress on these tasks and address any implementation challenges After completing the follow-up tasks, responsibility for maintaining improvements and analyzing data was handed over to the director of strategic initiatives.
To enhance patient flow, your team must develop a comprehensive communications strategy Regular meetings of the patient flow team are essential to share updates on PDSA cycles and the full-scale implementation process It's crucial to keep hospital and department leaders informed of progress at regular intervals This aspect of the improvement plan requires careful consideration of communication responsibilities and the establishment of a clear timeline for updates.
Step 3 Estimate the Time and Expenses Associated with
This section of the IP is focused on planning for the resources needed to get your patient flow improvement strategies implemented
To effectively plan and implement your strategy, it's essential for your team to estimate the total hours required We suggest creating individual time estimates for each staff member to set clear expectations regarding the time commitment necessary for the project's success.
Facilitating Change and Anticipating Challenges
This section outlines key facilitators for implementing emergency department (ED) improvement strategies, based on insights from hospitals involved in UMLN II Successful change often required anticipating potential challenges and proactively addressing them.
Securing leadership support is crucial for the successful implementation of improvement strategies, particularly those that require extra resources or affect departments beyond the emergency department (ED) Many UMLN II strategies necessitated the hiring of additional personnel, yet several hospitals faced challenges due to recruitment difficulties and hiring freezes The economic recession and financial constraints made it impossible for some hospitals to hire more staff without an executive champion to advocate for these needs.
Example 10 St Francis Hospital: Securing a Champion
St Francis Hospital in Indianapolis, IN, implemented front-end improvement strategies, notably through registration zoning, which designates staff to register patients in specific room zones using workstations on wheels (WOWs) Initially, hospital leadership hesitated to approve the purchase of WOWs due to budget constraints and a shift towards standardized mobile units However, with the backing of the director of business transformation, the chief operating officer advocated for the project, ultimately securing the acquisition of two WOWs The absence of WOWs until February 2010 hindered progress during the early stages of the initiative.
The UMLN II established a structured framework and a clear timeline for hospitals, ensuring that proposed improvement strategies were prioritized amidst various competing demands Participation in the program mandated that hospitals adhere to these guidelines, fostering external accountability for their implementation.
UM staff developed comprehensive implementation plans that outlined the necessary intermediate steps, required resources, and key personnel for executing their strategies Furthermore, the external accountability established by UM ensured that the proposed improvement strategies garnered the necessary focus, even amidst other significant projects, such as major hospital construction and the rollout of electronic medical records.
Many hospitals may not engage in formal collaborations, but establishing informal partnerships can still foster shared learning and accountability through commitments to report progress and share data The experiences of UM participants highlight the benefits of utilizing the IP template, which offers a structured approach for planning and implementing change, even without formal collaboration.
A supportive supervisor or senior leader overseeing multiple units can greatly enhance coordination, cooperation, collaboration, and compliance during changes An aligned reporting structure proved essential for the success of strategies at various UMLN II hospitals, where different hospital units and staff with diverse roles were engaged.
At UMLN II hospital, a new role of vice president for emergency medicine was created to oversee all emergency department (ED) operations, marking a significant shift as all ED physicians and nurses now reported to one leader This vice president emphasized the importance of enhancing patient flow, making the improvement of the fast track a departmental priority.
Involving a diverse range of staff in the planning, design, and execution of patient flow improvement strategies is essential for achieving effective and sustainable change By engaging those who will be affected by these changes, organizations can gain valuable insights and expertise, which helps to minimize potential resistance from staff in the future.
Lean process improvement methods effectively engage staff, as shown in two UMLN II hospitals These hospitals established multidisciplinary teams to analyze existing processes, implement efficiency-enhancing changes, and refine them through short testing periods until objectives were achieved Notably, one hospital's staff indicated that Lean tools fostered a clearer understanding among nurses regarding the rationale behind the changes.
Selecting capable and adaptable staff to lead change is crucial The planners at two hospitals recognized that not all employees would initially support the new strategies, so they chose individuals committed to testing the process changes These employees emerged as champions for the initiatives, effectively persuading their colleagues of the strategies' benefits.
Engaging in Robust Data Collection
Effective data collection is essential for performance improvement teams to secure necessary resources and overcome staff resistance For instance, demonstrating the issue of crowding through data was vital in gaining the support of an administrative champion at a UMLN II hospital Additionally, this data can help convince leadership that emergency department (ED) overcrowding is a hospital-wide concern, thereby increasing the chances of obtaining support for strategic initiatives Furthermore, sharing data with staff allows them to recognize the positive impact of their efforts.
Realistically Appraising the Need for Resources
Being realistic is essential for success in hospital operations Teams must ensure they have adequate resources and comply with all regulations Success should not rely on reallocating staff from other departments For instance, one hospital recognized the necessity of a dedicated nurse and technician for their fast track unit, but their request for additional support was denied This led to staff being taken from the emergency department, which one respondent described as "robbing Peter to pay Paul." Another hospital emphasized the importance of having dedicated personnel, highlighting that strategies should not depend on diverting staff from the main emergency department.
Anticipating and Addressing Staff Resistance and Culture Change
Staff resistance is commonly faced due to heightened workloads and disruptions in established workflows In UMLN II, certain proposed strategies conflicted with departmental culture, making it challenging for patient flow improvement teams to shift attitudes and habits Past failures in quality improvement initiatives fostered cynicism among staff Ultimately, culture prevails over strategy, emphasizing the need to transform mindsets.
The patient flow improvement teams in UMLN II hospitals effectively addressed staff resistance and promoted culture change through various strategies A key approach was the emphasis on staff education and reeducation, highlighting the belief that continuous learning is essential for success, as noted by a staff educator who stated, “there can never be enough education.”
Sharing Results
Effective communication of performance improvement projects and their outcomes across all affected departments is essential for closing the feedback loop and promoting continuous quality enhancement As front-line staff recognize their capacity to drive and maintain improvements, their motivation to pursue further advancements increases Sharing results from multiunit or multidepartment initiatives fosters a culture of transparency and encourages healthy competition among units striving for better performance Additionally, utilizing ED dashboards offers stakeholders a clear overview of critical process variables.
Figure 4 Data reporting practices at six UMLN II hospitals
Data routinely sent to: Number of hospitals reporting:
The UMLN II evaluation highlighted that internal accountability and momentum fostered by collaborative participation are key to improvement Even if not all hospitals can engage in formal collaborations, they can still generate momentum by sharing their results with external stakeholders This can be achieved through community partnerships, written publications, and conference presentations Examples of potential partners include community social service organizations, other hospitals within a system or regional associations, as well as local newspapers, blogs, and trade publications like Hospitals & Health Networks and Modern Healthcare.
Healthcare), peer-reviewed journals (e.g., Joint Commission Journal on Quality and Patient Safety,
Journal of Emergency Medicine, Journal of Emergency Nursing), and professional societies (e.g.,
Society for Academic Emergency Medicine, American College of Emergency Physicians, and
Prolonged stays in the emergency department for patients with non-ST-segment-elevation myocardial infarction (NSTEMI) are linked to poorer adherence to the guidelines set by the American College of Cardiology.
Cardiology/American Heart Association guidelines for management and increased adverse events Ann Emerg Med
2 Fee C, Weber EJ, Maak CA, Bacchetti P Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia Ann Emerg Med 2007; 50(5):501-509.e1.
3 Schull MJ, Vermeulen M, Slaughter, G, et al Emergency department crowding and thrombolysis delays in acute myocardial infarction Ann Emerg Med 2004; 44(6):577-585.
4 Hwang U, Richardson L, Livote E, et al., Emergency department crowding and decreased quality of pain care.
5 Pines J, Hollander J Emergency department crowding is associated with poor care for patients with severe pain.
6 Niska RW, Bhulya F, Xu J National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department
Summary National Health Statistics Reports, No 7 Hyattsville, MD: National Center for Health Statistics; 2010.
7 McConnell KJ, Richards CF, Daya M, et al Ambulance diversion and lost hospital revenues Ann Emerg Med
8 Pines JM, Batt RJ, Hilton JA, Terwiesch C The financial consequences of lost demand and reducing boarding in hospital emergency departments Ann Emerg Med; in press.
9 Medicare Program: Hospital Inpatient Prospective Payment System Federal Register 2012 IPPS Final Rule
10 Medicare Program: Outpatient Prospective Payment System Federal Register 2011 OPPS Final Rule; 2010.
11 National Quality Forum endorses measures to address care coordination and efficiency in hospital emergency departments Press release, October 29, 2008 Washington, DC: National Quality Forum; 2008.
12 Institute of Medicine Hospital-based emergency care at the breaking oint Washington, DC: National Academies
13 The 1995 Accreditation Manual for Hospitals Oakbrook Terrace, IL: The Joint Commission; 1995.
14 Cracking the Code to Hospital-wide Patient Flow Denver, CO: Institute for Healthcare Improvement; 2011.
15 Wilson MJ, Nguyen K Bursting at the Seams: Improving Patient Flow to Help America’s Emergency Departments.
Washington, DC: The George Washington University Medical Center; September 2004
16 Improving Patient Flow & Reducing Emergency Department Crowding Washington, DC: The George Washington
University School of Public Health and Health Services; February 2010.
17 Silow-Carroll, Alteras, T., and Meyer, J.A Hospital Quality Improvement: Strategies and Lessons from U.S.
Hospitals New York: Commonwealth Fund; April 2007 Available at www.commonwealthfund.org/Publications/Fund-Reports/2007/Apr/Hospital-Quality-Improvement Strategies-and-
18 Timmel J, Kent PS, Holzmueller CG, et al Impact of the Comprehensive Unit-Based Safety Program (CUSP) on safety culture in a surgical inpatient unit Jt Comm J Qual Patient Saf 2010; 36(6):252-260.
19 Science of Improvement: Forming the Team Washington, DC: Institute for Healthcare Improvement; 2011.
In 2009, the National Center for Health Statistics published a report by McCaig, Xu, and Niska that estimates the capacity of emergency departments in the United States for the year 2007 The full report can be accessed at the CDC website.
ED_capacity.pdf Accessed October 17, 2011.
21 McClelland MS, Jones K, Siegel B, Pines J A field test of time-based emergency department quality measures. Ann Emerg Med 2011; epub.
Appendix A Guide to Online Resources
Successfully Used by Hospitals to
Improve Patient Flow n The Urgent Matters Toolkit
This comprehensive toolkit features more than 50 effective strategies designed to alleviate emergency department (ED) crowding and enhance patient flow Each strategy is detailed with its outcomes, relevant hospital demographics, involved staff types, impacted clinical areas, implementation timelines, experiences, lessons learned, and cost/benefit analyses Access the toolkit at http://urgentmatters.org/toolkit, provided by the American Hospital Association (AHA) Hospitals in Pursuit of Excellence.
This Web site includes more than 25 case studies that focus on improvements in ED throughput.
These case studies focus on the problem, solution, results, background, impact on patient flow, resources expended, sustainability, patient and staff perceptions, and how the strategy meets the
Institute of Medicine’s six aims Available at http://www.hpoe.org/ n Agency for Healthcare Research and Quality (AHRQ) Innovations Exchange
The Innovations Exchange features more than 75 innovative solutions aimed at enhancing emergency department (ED) patient flow and alleviating crowding issues Each entry details the innovation's purpose, implementation strategies, outcomes, and important factors to consider for successful adoption For more information, visit [Innovations Exchange](http://www.innovations.ahrq.gov/).
The Institute for Healthcare Improvement (IHI) offers four stories on emergency department (ED) improvements and eight valuable resources that emphasize strategies for enhancement, measurement, and literature Their website also provides various tools aimed at improving patient flow in the ED, including an hourly patient flow analysis tool, accessible at [IHI's website](http://www.ihi.org).
ENA's Successful Solutions to Crowding website presents eight effective strategies categorized into four key areas: access, throughput, ancillary, and disposition For more information, visit [ENA's official site](http://www.ena.org) This resource is endorsed by the American College of Emergency Physicians (ACEP).
ACEP offers valuable resources on Emergency Medicine Crowding and Boarding, aimed at helping emergency physicians tackle crowding issues in emergency departments These resources facilitate collaboration with hospital administrators, local stakeholders, policymakers, and the public Additionally, a members-only section features case studies on crowding, providing further insights For more information, visit [ACEP's website](http://www.acep.org/).
Barriers to Successful Implementation (actual or potential)
Method of Improvement (check one or more)
Activity (e.g., data collection, staff training, Who is responsible? Due Date development of new forms, purchases)
Who needs to What information When do they need Who will provide the know about the do they need? the information? information? strategy?
Estimated Number of Hours for Implementation
Role Name Number of hours Number of Total number of per week weeks hours
Name Issue for Approval Date Approval Date Approval
Performance Measures (check all that apply)
ED Arrival to ED Departure – Admitted Patients
ED Arrival to ED Departure – Discharged Patients Admit Decision Time to ED Departure
Improvement Strategy Name: Mid-Track: The Solution to the ESI 3 Conundrum
Hospital: Good Samaritan Hospital Medical Center
In 2007, we identified that our left-without-being-seen (LWBS) rate of 3.5% was higher than acceptable.
We implemented a plan to address this issue, and the LWBS rate dropped by nearly 45% Though this represented a dramatic reduction, this rate eventually “plateaued” over the next 2 years at 2%
Our analysis revealed that patients classified as Emergency Severity Index (ESI) 3 constituted the largest subgroup among those who left without being seen (LWBS), accounting for over 75% of all walk-outs Notably, 85% of these patients presented with one of six common chief complaints and experienced the longest wait times before being evaluated by a physician.
Our goal is to enhance the care for the ESI 3 patient subpopulation by decreasing walk-out rates by 25% and ensuring an average time-to-provider of under 60 minutes We aim to accomplish this within three months of our implementation date, set for August 4, 2009, with the target to achieve these improvements by the end of October 2009.
We will focus on a specific group of ESI 3 patients impacted by this strategy, which includes individuals presenting with chief complaints such as abdominal pain, vaginal bleeding, pregnancy complications, vomiting, flank pain, or headaches Additionally, this subset will consist of patients who meet established criteria and those arriving at the emergency department from Monday to Friday between 4 p.m and 11 p.m.
To expedite care for ESI 3 patients, we propose a two-step process First, we will add a physician to triage from Monday to Friday, between 4 p.m and midnight, with potential for extended hours and weekend coverage ESI 3 patients will be directly referred to this physician for evaluation and necessary tests The second step involves utilizing the ambulatory surgery unit (ASU), located one floor above the emergency department, as a dedicated area for ESI 3 patients Here, a nonphysician provider (NPP) will manage patient care in coordination with the physician in triage.
To implement this strategy, we first had to identify an area of the ED that we could assign as the mid-track.
We attempted to reassign one of the four geographic districts within the Emergency Department (ED) to manage patient flow more effectively However, the remaining districts became quickly overwhelmed with ESI level 1 and level 2 patients, leading to an unequal distribution of acuity among the three districts This situation resulted in numerous staff complaints, prompting us to terminate the pilot program after just one month Consequently, we recognized the need to find an alternative space to accommodate mid-track patients.
The ASU is located directly above the ED, close to the ED staff and radiology services, operating from 6 a.m to 6 p.m., with a notable drop in patient volume at 4 p.m After discussions with administration, we received approval to utilize this area post-4 p.m., subject to specific conditions.