Turn to staff for boost in productivity

Volunteer team members weed out inefficiencies

When it's typical for patients to wait four hours or more to see an emergency physician, and your leave-without-being-seen (LWBS) rate is pushing 10%, you know it's time to rethink the whole process. And these were the grim realities facing the ED at Baylor Medical Center in Garland, TX, as recently as two years ago, explains Steve Arze, MD, the medical director of the ED.

"We had hit the point where our waiting times had just become too long to be safe," he says. "While there are certainly places in the nation where the wait times are longer, we were not in a place that we felt was appropriate for our patients."

Taking a closer look at the problem, administrators quickly realized the issue was hardly inadequate staffing levels. "As patients would pile up in our waiting room, there were doctors who were not seeing patients and nurses who were not seeing patients," says Arze. Instead, what was gumming up the process was a triage plan that was packed with too many unnecessary steps. "There is no reason to wait to see a triage nurse, for instance, if there are plenty of beds open in the area where patients need to go," adds Arze.

The ED managers could have re-engineered the process themselves but, instead, they handed the problem to a cross-section of ED staff who volunteered to put the patient-flow process under a microscope and identify inefficiencies, explains Brennan Bryant, RN, MSN, MSHCAD, the hospital's director of emergency services.

"They developed solutions to the bottlenecks," says Bryant, and the results have been stunning. The average length-of-stay (LOS) for patients discharged from the ED has decreased by 36 minutes, and the average LOS for admitted patients has decreased by 91 minutes. "In essence, we have added 11 beds without really changing anything other than the process flow through the ED," adds Bryant. "It's phenomenal."

Take a team approach

To get the volunteer team started, management collected detailed time metrics on every portion of the patient-flow process from arrival to triage to the total LOS, explains Bryant. "We mined that data and presented it to them so they could basically brainstorm around what [changes] they felt would deliver the most bang for their buck," he says.

The team pored over the data and came up with 33 processes and efficiencies that could be improved; then the challenge was to whittle that list down to a workable group of changes based on frequency of occurrence and the impact on overall LOS, adds Bryant.

For example, the group streamlined the triage process so that patients are now asked a minimal number of questions — just enough to ensure that they proceed to the most appropriate area for care, which is either a location designated for lower acuity complaints or the main ED, explains Arze. "A full triage, including extensive histories about what happened to the patient, why they are there, what type of medicines they are on, and who their physicians are — all of that can be done later and does not need to be obtained before the patients are connected with a physician," he says. "The triage really becomes a quick screen to determine what area the patient needs to go to, and then a primary nurse gets the remainder of the information about that patient at a later point."

Another change to the process is that physicians no longer have to wait until a chart is generated by a nurse before they see the patient, says Arze. "We have a team approach in that either of them can go on independently to see the patient."

If the physician sees the patient first, he or she will go ahead and take the history and issue orders without waiting for the nurse. This enables the team to see several people at a time rather than waiting for each patient to come through the process in a sequential manner, explains Arze.

Looking beyond triage, the volunteer team realized that efficiencies could be gained by enabling lower-acuity patients to travel from one point of care to the next on their own rather than being escorted by staff. To facilitate this "standard conveyance" model, the staff developed signage on the walls and floors so that patients could be easily directed to the right place, explains Bryant. "For patients headed to radiology, for example, we have these little bones on the floors. The patients are taken to where the bones start, and then they are told to follow the bones down the hall, turn to the right, and have a seat in the chairs where someone from radiology will pick them up," says Bryant.

A computerized tracking system lets ED staff know where patients are throughout their ED stay, adds Bryant. There are more than 40 computer monitors in the ED so that a monitor is available about every 10 feet to let staff see where a patient is on his or her journey, he explains. "They can see whether labs have been ordered, drawn, or returned, and the same thing for radiology and other procedures," adds Bryant.

Some job responsibilities have been realigned as well. For example, in the past, the charge nurse would typically take care of some of the sickest patients and assist staff when they became overloaded, says Bryant. "The team found that we had lost that high-level vision of what is going on in the whole ED ... so they rewrote the job description of the charge nurse to pull [this person] out of direct patient care and put him or her back where the position needs to be, which is as kind of the traffic cop of the ED," says Bryant. "That has worked very well."

The volunteer team also observed that roughly 46% of the ED's volume was being handled in seven rooms that make up the rapid medical evaluation area, but these rooms were under-staffed, so they adjusted the staffing matrix to better support this area, says Bryant. However, as they addressed staffing for the lower-acuity patients, they found that this change also lessened LOS times for the more acute patients. "For patients admitted to the hospital, LOS in the ED was decreased by 91 minutes," adds Bryant.

Much of this improvement can be explained by the snowball effect that having success can create, suggests Bryant. "Once the team started to see results from the process changes that they had envisioned, it became kind of a self-fulfilling process," he says. "Success breeds success, and when the turnaround times began to rapidly go down, everybody realized that working together as a cohesive unit and actually bringing the patient into the care team really helps to effect change."

Any type of change is likely to prompt questions or even skepticism when people are used to doing things a particular way, but Arze stresses that in this case, there wasn't much grumbling. "On the physician side, we were able to increase the number of shifts that we had because our productivity increased so much," he says, noting that the revenue to pay for these shifts came from capturing paying patients who previously left without being seen. The LWBS rate has dropped from 10% to 2% since the improvement process began, adds Arze.

The improvements are also evident in the brand-new ED that the hospital constructed about six months after the improvement process began. "We now use less space than we used to in our old ED to see the same number of patients," says Arze. "It's just purely because of the improvements in efficiency that we have achieved. Patients don't linger in our beds for a long time because we are able to move them through quickly. That has enabled us to essentially reduce the number of beds that we have to have operational at any one time."