Patient Flow Solutions

ED leaders reverse poor flow trends

Satisfaction ranking: From 'worst to first'

How's this for a turnaround? A few years ago, patient satisfaction levels in the three EDs of the Cambridge (MA) Health Alliance were in the lowest decile in Massachusetts, and now they are consistently in the top quartile. In fact, adds Assad Sayah, MD, FACEP, chief of emergency medicine for the system, "In the last couple of months, we've been in the first or second percentile in the state."

This turnaround in patient satisfaction is the result of broad-based undertaking to improve patient flow and the patient experience in the EDs, which has achieved several other impressive results. For example:

  • Door-to-doc time has been reduced from 90 minutes to 12 minutes.
  • The rate of patients who have left without being seen (LWBS) has fallen from 4.8% to less than .5%.
  • The average length of stay has decreased by 13% to 2.5 hours.
  • The EDs, which used to be on diversion 8% of the time, have not gone on diversion in four years. During those four years, the total volume for the three EDs has risen from about 80,000 patients a year to 100,000 patients a year.

Shortly after he arrived, Sayah recalls, the ED leadership was put in charge of a multi-disciplined group whose task was to improve flow in and out of the ED. "When I got here, things had been done the same way for a very long time," says Sayah.

Sayah says he had a lot of support from the administration. The group he headed represented not the ED, administration, radiology, the lab, and admissions. It included nurses and physicians, including hospitalists. Recommendations for improvement came from many different areas. "One person cannot affect change. You have to own flow as an institutional problem, not just the ED's problem," he says. (Leadership was critical to the culture change required to accomplish this improvement. See the story below.)

Still, it was the ED that had to lead the way, says Luis Lobon, MD, MS, FACEP, the site chief of emergency medicine at the Cambridge Hospital campus, who came on board shortly after Sayah did. "What was very clear from the beginning was that we needed to clean our own house," he says. "We were not expecting miracles from the other departments."

So, the ED "pioneered" the change by eliminating diversions two years before such a practice was mandated statewide. Lobon says, "By doing things of that nature, it sent a clear message that we were dedicated to changing the experience of the patient."

Still, says Sayah, the "biggest piece" of the process centered around the other departments. "You can do all you want to upfront, but if you can't decompress the ED from boarded and admitted patients, you are fighting a losing battle," he says. "Three of the five teams addressed these issues: doctor-to-doctor handoffs, nurse-to-nurse handoffs, and early patient discharges."

Adding a "partner"

In terms of new process changes "up front," one of the most notable was the creation of the position of "patient partner." This is a non-clinical individual who Sayah likens to the host/hostess who first greets you when you enter a restaurant.

"They are helpful PR people who can answer your questions in more than one language," notes Sayah. On two of the campuses, that position is staffed 12 hours a day, and on the third that position is staffed 18 hours a day, he says.

"When the patient comes to the door, the first person that meets them is the patient partner," says Sayah. "He speaks to them in their language. If they cannot, we have a translation phone that answers immediately."

The patient partner asks the patient three questions — name, date of birth (or social security number), and chief complaint. "They do a 'mini-reg' which take 30 seconds, after which that information is accessible by computer to all of us, so we can order tests and produce a chart," Sayah explains. "The patient partner creates the initial chart, puts the bracelet on the patient, and brings them to the ED immediately so there is no sitting involved."

There is no waiting room. In fact, Sayah adds, the reception areas ultimately might be converted to clinical use. Lobon says, "The most important principal involved here is that the patient comes to the ED to see a physician. They do not come to watch TV, or see a triage nurse, or talk to registration about insurance. They want a physician, and that's what we give them."

Most of the patients (those requiring sub-acute care) are taken to the rapid assessment area. "Historically this area was occupied by express care, [ED] administration, and triage," says Sayah. "We merged the space together and the staff together."

For example, notes Sayah, the department previously had one triage nurse and two express care nurses. Now it has three rapid assessment nurses. "There is no bottleneck," he says. "Two EDs have five rapid assessment rooms, and one campus has nine, all of which have nurses and PAs; the doctors have been moved to the acute side."

Sayah says that 40% of patients never move out of the rapid assessment area. Registration personnel will perform a bedside registration using a wireless mobile registration station. "The patient is discharged right from the same room," says Sayah.


For more information on improving patient flow, contact:

  • Luis Lobon, MD, MS, FACEP, Site Chief of Emergency Medicine, Cambridge (MA) Hospital. Phone: (617) 665-1712.
  • Assad Sayah, MD, FACEP, Chief of Emergency Medicine, Cambridge Health Alliance. Phone: (617) 665-2356.

Management Tip

Secret to making a culture change

The dramatic improvements achieved in patient flow at Cambridge (MA) Health Alliance could not have been possible without culture change, says Assad Sayah, MD, FACEP, chief of emergency medicine for the system.

"Culture change starts from the leadership setting the expectations for everyone else and being available and willing to support the ED," Sayah says. "It's easy to dictate to people what to do, but you really have to lead by example and work harder than anyone else, and be available 24/7 and help the staff whenever they need it."

Such change also requires teamwork, Sayah says. "We work hand in hand with nursing leadership and the ED administrator; we look at leadership of the department as a tripod," he notes. "All three of us work hand in hand to be on the same page, making it possible for everyone across disciplines to sing the same song before implementation of new processes begins."