ED’s paradigm shift cuts costs, streamlines care, improves quality

Hospital emerges with two departments within one

In 1995, the cost per visit at Parkview Memorial Hospital’s Emergency Care Center was $70, $10 above the national average. Patients waited 90 minutes to see a doctor. Satisfaction hovered around the 46th percentile based on the Press, Ganey satisfaction survey peer group ranking.

In 1997, the cost per patient visit is $58 and falling; patients wait less than 30 minutes to see a doctor. Satisfaction scores have jumped to the 86th percentile.

With all this improvement, patient volume in the emergency department (ED) rose 3.5% from 51,529 in 1995, to 53,333 in 1996. This year, volume in the emergency department of the Fort Wayne, IN, hospital is already running 7% higher than in 1996.

These dramatic improvements are attributed to a staff-run performance improvement team that re-engineered the whole department, says Daniel A. Garman, division director of emergency services at Parkview.

"Two years ago, we didn’t have this level of energy, this kind of innovation," Garman says. "Everyone’s taking accountability for improving processes. They’re always asking why we do something a certain way."

In September 1995, Parkview formed the team called the ECC Departmental Focused Review Team to evaluate and, if necessary, redesign the emergency department. It consisted of three ED staff nurses, an emergency physician, three department managers, Garman, and two advisors from the hospital’s business and resource planning department. It met for two hours every Monday for nine months. The team keeps hospital personnel up to date on its progress through a newsletter and e-mail messages highlighting meeting activities.

Building on total quality management efforts in place since 1992, the team identified four goals:

1. Slash overall cost performance to at or below $60 per visit.

2. Boost patient satisfaction.

3. Boost staff and physician satisfaction.

4. Meet or exceed length of stay goals in the department for each of the separate areas.

The team had the support of the administration to act on its decisions. In fact, Parkview had just spent $9 million renovating and expanding the ED to 20,800 square feet and 46 beds as part of its improvement plan. The renovation included such technological innovations as a new radiology system that cut the cycle time for X-ray patients in half to an average 20 minutes; a supply inventory/order stocking system that generated $150,000 savings in its first year of operation; a pneumatic tube system tied directly to the laboratory; an installation of a patient tracking and management system; and separate areas for specific types of patient conditions.

The team began its improvement program by analyzing the business of the ED. The team pored over data related to activity in the department and examined the patient population and processed flowcharts. At the end, they reached a conclusion that resulted in a paradigm shift. They determined Parkview’s ED really had two businesses: emergent care and urgent care. The department was split along those lines. The team also looked to streamline processes and decided to revamp the staffing model to slash overtime averages from 300 hours every two weeks to 92 hours. The redesign also enabled the hospital to cut labor costs, reduce its nurse ratio from 70% to 60%, and increase the number of full-time equivalent staff. (See related story, p. 64.)

Armed with the new paradigm, the Review Team sought benchmark partners that excelled in either emergent or urgent care, while recording lower costs and higher satisfaction scores. The team initially identified 28 hospitals through a phone survey. The list was quickly trimmed to three when it was decided they would save money by choosing regional partners: Columbus (IN) Regional Medical Center; Miami Valley Hospital in Dayton, OH; and Community Hospital in Indianapolis.

At Columbus, the team discovered bedside registration, an advancement that single-handedly dealt with the problem of an excessive wait time in the ED. Columbus used laptop computers to register patients. The initial information gathered at the bedside goes into the ED patient tracking system. If the patient is to be admitted to the hospital, the same laptop can access the hospital’s main patient registration system.

"We know from our surveys that patients who come to the ED expect to be put in a bed," Garman explains. By quickly putting patients into an urgent care room and taking information at bedside, Columbus Regional’s ED staff gave patients what they wanted and shortened the registration process.

Fortunately for Parkview, during the renovation, information system specialists had recommended the ED rooms be wired for computers, enabling a smooth installation of a similar bedside registration process.

Parkview currently registers 22% of its patients at the bedside but plans to raise that number to 75% by the end of the year.

The new system immediately slashed the hour and a half wait to see a doctor to about 30 minutes. It also eliminated the need for urgent care patients to trundle back and forth to a central registration desk up to four times, cutting the average length of stay in urgent care from 113 minutes to 73 minutes.

Part of Parkview’s successful implementation of the new registration process is attributed to another tactic learned at Columbus called a "breakthrough" event. This event is an accelerated improvement technique that involves bringing all the "owners" of a process together for brainstorming, a quick consensus on action, and then a short (usually only a few weeks) implementation period. (See related story, p. 63.)

At Miami Valley Hospital in Dayton, the Review Team learned staff there had been trained to use scripts for dealing with patients. The scripts covered such issues as waiting times, leaving against medical advice, and visitor policies. As a result of this site visit, the Review Team developed five scripts for use at Parkview:

1. calling patients’ physicians;

2. signing out against medical advice;

3. the ECC’s visitors policy;

4. explaining the triage process;

5. communicating with patients concerning privacy.

"These help the staff communicate more realistic expectations to patients," explains Garman. "Instead of a nurse saying, ‘I’ll be back in a moment’ when she really means five to 10 minutes, we’ve trained our nurses and doctors to say things that give patients the information they need without raising unrealistic expectations. The patients are happier because we then meet their expectations."

The hospital’s education council trains the ED personnel, and the scripts are posted prominently in key staff areas. Garman credits the scripting with the jump in the ED’s patient satisfaction scores.

The Review Team continues to search for ways to improve the department. Ideas under consideration include establishing a care center for children who come to the ED with sick parents and opening a clinic at 6 a.m. for children who are sick and need an antibiotic so they can still be dropped off at day care. Garman says such a clinic would relieve parents of the burden of skipping work to wait for a doctor’s appointment.

"You have 200 brains out there, and they have a lot of good ideas," Garman says. "You need to tap these resources. Not everything will be a good idea, but you’ll be amazed at what they come up with."

[For more information, contact Dan Garman, division director for emergency services, Parkview Memorial Hospital, 2200 Randallia Drive, Ft. Wayne, IN 46805. Telephone: (219) 484-6636, Ext. 60160. Or visit Parkview on the World Wide Web at www. parkview.com.]