The typical emergency department (ED) is a case study in dealing with catastrophe and chaos…at least on television. Even in the real world, 24/7 ED operations have tremendous flux and uncertainty. During the busiest times, staff members may struggle to stay ahead of patient problems, leading to slow throughput in the process, translating to long waiting times for patients.
Ask many ED visitors if they feel their issues received “emergency treatment” and they will say no. When patient waiting time is longer than expected, overall patient satisfaction declines. Most emergency departments have plenty of opportunity to improve.
Begin with assessment and alignment
As with any improvement process, assessment is a great first step in the path toward operational excellence. This generally takes the form of measurable observations and surveys. For example, you might ask the ED operational leadership team questions in areas such as these:
- Has patient demand been tracked over time?
- Has the team used tools such as value stream mapping and structured problem solving to examine ED and patient flow, identifying and tracking all the process steps?
- Has a desired future state for patient flow with desired time intervals for each process step been identified? (Takt time in Lean terminology)
- Has the staffing plan been assessed against patient demand, with bottlenecks and idle time identified?
- Has the team investigated technology to improve process steps?
- Does the operation team have relevant metrics for operational excellence, including real-time process monitoring and lagging indicators of patient and employee satisfaction?
- Does the team share performance metrics with staff? With the public?
The team will likely formulate plans to address any “no” answers to these questions. All of this work needs to be evaluated and integrated to create an improvement strategy and objectives aligned with the health care organization’s overall strategies and goals.
Develop a tactical plan for improvement
When the target ED throughput goal is identified, an operational excellence team of skilled continuous improvement practitioners and knowledgeable ED team members will define, prioritize and manage a tactical plan for delivering the desired process improvements.
A value stream map identifies areas of opportunity along the patient flow. From this helpful view of the process, the team will identify projects that impact the whole patient flow as well as complementary projects at each process step.
For example, if a team finds that they don’t have a system in place to measure patient flow, they may decide to implement manual tracking or purchase patient flow software, which can standardize tracking to shorten throughput and reduce errors. To address a specific bottleneck in registration, the team may introduce kiosks or mobile registration that can reduce the amount of staff time needed in this step while improving wait time perception by keeping the patient engaged rather than sitting idle.
These and other project ideas become part of the process improvement portfolio, managed by the team to deliver clear prioritization, buy-in, communications, and accountability.
Implement projects to drive progress
In the implementation phase of the improvement effort, the team follows an iterative process to deploy, assess and sustain best practices. As projects are implemented, real-time measurements verify that the changes are effective. In many cases, short runs or pilot trials are used to test improvement ideas. Based on observed results, the changes are tweaked for optimization and scaled up for full operation.
At times the assessment will show that bottlenecks come from associated services. X-ray, lab services, pharmacy, and billing may be separate departments within the hospital, but the ED patient sees any delays in these areas as ED problems. Representatives from these areas are engaged in the improvement efforts to optimize overall performance and maximize the perception of quality and timeliness for the total patient experience.
Standardized procedures, training, tracking, and corrective action processes are also included to ensure improvements are sustained over time. Planned reviews are an important part of this process to ensure that projects and results are on track and to engage stakeholders in busting barriers, providing resources, and reinforcing progress.
Measure progress and results
The measurement part of the improvement effort includes defining, tracking, and managing process and project level measurements and organizational key performance indicators (KPIs). Many of the process metrics can be gathered unobtrusively by staff members or by an electronic interface. Patients have become used to wristband scanning for identity verification; this type of information can be used in a process flow tracking system to log times for each process step. Typical metrics include:
- Wait time for admitted and non-admitted patients
- Patients leaving without being seen and wait time before they leave
- Time from admission to actual placement in a bed
- Number of patients admitted and transferred per day, by day of the week and time of day
- Breakdown of patients for age range (pediatric, adult, geriatric), issue type and acuity, and payor classification
These quantitative measurements provide the data for creating the value stream map and conducting problem-solving sessions. Real-time process indicators can also trigger problem resolution actions built into the implementation plan or lead to new project activity. In addition, department costs, patient satisfaction surveys and employee satisfaction surveys can provide longer-term verification that the progress made is driving toward desired overall performance. The Centers for Medicare & Medicaid Services provides sample patient surveys.
During times of change, monitoring employee satisfaction is extremely important. Hopefully employees are active contributors to the improvement plans, both to utilize their extensive process knowledge and to build their commitment to any agreed changes. Even when employees are engaged in the process, changes in daily routines can cause stress and dissatisfaction that must be addressed.
One quality observation is “what gets measured gets improved.” Having the measurement for ED throughput in place can be a powerful motivator to drive improvement. It’s not just an internal metric, but can have significant impact on patient volume and the organization’s bottom line. ER WaitWatcher provides a standardized measurement for wait time at major facilities nationwide, including drive time if desired, so patients can choose the location where they can expect to be seen most quickly. Some hospitals even provide expected wait times on their own websites to show their competitive performance and help manage customer expectations.
Pulling it all together
Many of the people involved in emergency departments are skilled in the technical and social aspects of patient care. They’re also used to dealing with crisis management. However, they may feel they don’t have the bandwidth to make systematic changes to drive long-term improvements in throughput. They also may not have the experience or self-confidence in operational excellence methods to pursue this path.
EON has the combination of experience managing operational excellence and software solutions that can make this job easier. Take the first step and contact EON to start an assessment of your operations and begin your path to improvement that lasts.
