Want to improve service? Promise a 30-minute wait

Even if you don’t want to offer a service guarantee like those EDs that promise to treat patients in 30 minutes or less, you probably wouldn’t mind streamlining your ED and improving patient flow through. So how do those hospitals promising fast service improve their EDs enough to make that promise possible?

At St. Charles Mercy Hospital in Oregon, OH, a "30-minute ED promise" required significant improvements in ED operations, says Dayle Pugh, RN, BSN, CEN, clinical director for emergency services.

The hospital promises that patients will be seen by a physician within 30 minutes of entering the ED, she says. If the ED fails to make that time limit, the patient is offered a $15 gift certificate to a local restaurant or department store.

Triage processes were revised in the biggest single change, and in the end, operations were improved enough that left-without-being-seen statistics went from 0.74% to 0.25%.

"Triage was where we captured the majority of our time savings. We have a lot of parallel processes now with a quick registration process," Pugh explains. "We also changed our triage process from a very thorough one to a much shorter one."

The same 30-minute promise is offered at St. Anne Mercy Hospital, a sister facility in Toledo, where Kenneth Chelucci, MD, FACEP, medical director of emergency services, says the ED also had to increase physician and nurse staffing.

To improve patient flow through and also to anticipate an increase in volume as the promise was marketed, Chelucci ensured that the 17-bed ED has three physicians working most of the day, and a fourth is available for busy periods.

Chelucci and his staff also started paying more attention to which rooms patients were placed in for the initial examination.

"For instance, if we have a woman come in with abdominal pain, we try to make sure she’s placed in a setting where she could undergo a gynecological exam if necessary, rather than having to wait for such a room to empty because we put someone else there," he points out.

Placing patients in the best possible exam room is the responsibility of the receiving nurse who escorts the patient from the waiting area.

Faster registration a key

Another big change took place at registration, where staff must generate a medical record case number very quickly and with very little information. The registration staff take only enough information up front to prevent generating a duplicate record number — generally only the patient’s name and Social Security number.

"Then they have to go to the patient or family member later and collect the rest of the information and ask about any updates to what was previously in the record," Pugh says.

Bedside registration had been used in the past, but without the quick registration generating a patient number up front because it seemed like a duplication of effort to do the quick registration and the bedside registration.

That led to delays when the doctor showed up in the exam room before the registration clerk and could not order tests without the patient number.

The goal of the process changes is to keep the patient moving through the system, Pugh says. In fact, "if we ever have to put a patient out in the waiting room because triage is backed up, we know that it’s almost impossible to make that 30-minute deadline," she says.

And the ED is not just shifting the wait time from the waiting room to the exam room. The hospital’s length of stay in the ED, whether admitted or discharged, used to be 2.8 hours. After implementing the process changes, that time dropped to 1.8 hours.

Other changes were aimed at keeping patients moving out the back end of the ED. Discharge instructions were streamlined, and with substantial help from upper administration, the ED negotiated agreements with other units to take admitted patients from the ED much more quickly to available beds.

Pugh and Chelucci emphasize that such improvements will be extremely difficult, if not impossible, without top-level support from administration at the outset.

Upper-level administrators can bring disparate departments together and cut through much of the bureaucracy and interdepartmental turf wars, they say.

The sharp decrease in wait times and length of stay were a saving grace once the hospital went public with its 30-minute promise.

Volume increased 30% in a week at St. Charles. From an average of 94 patients a day, the hospital started seeing 130 patients a day in the 26-bed ED.

Last year, the hospital treated 41,000 patients in the ED. The hospital makes good on its 30-minute promise more than 90% of the time, Pugh says. Also, the ED virtually has no patients who leave without being seen, she explains.

Chelucci says few patients leave his ED at St. Anne Mercy without being seen as well.

At St. Charles, patient satisfaction scores had been in the range of the 85th percentile for years but jumped to the 99th percentile in the first quarter after the implementing the process changes and the service promise.

"Patients love anything that keeps them from waiting," Pugh says. "They don’t really care what you did to make that happen, but it leaves them with a much better feeling about your ED."

Sources

For more information on the 30-minute promise and improving patient flow through, contact:

  • Kenneth Chelucci, MD, FACEP, Medical Director, Emergency Services, St. Anne Mercy Hospital, 3404 W. Sylvania Ave., Toledo, OH 43623. Phone: (419) 407-2663.
  • Dayle Pugh, RN, BSN, CEN, Clinical Director, Emergency Services, St. Charles Mercy Hospital, 2600 Navarre Ave., Oregon, OH 43616. Phone: (419) 696-7200.