ED redesign puts all patients on fast-track
ED redesign puts all patients on fast-track
Radiology wait plunges to less than 30 minutes
By streamlining processes in its radiology department, Overlook Hospital in Summit, NJ, significantly cut the turnaround time for an emergency department (ED) patient’s film.
Patients previously waited an average of 70 to 90 minutes for their plain films to be read. Now, they have their diagnoses in less than 30 minutes, says James Espinosa, MD, medical director of the hospital’s ED.
The hospital has boosted the turnaround through one key change film now is sent directly to the ED physician for a quick read. In the past, the physician would have to wait for the radiologist to read the films and for the radiology tech to relay the results.
"Before it was geared to the doctors," Espinosa says. "Radiology wouldn’t read the film until they had all the films. Now it’s focused on the patient."
The reduced wait time has boosted patient satisfaction from the 23rd percentile to the 86th percentile on the Press, Ganey satisfaction survey within three months of implementation.
The change has earned the hospital an Ernst & Young Quality Award from the Society of Ambulatory Care Professionals.
For several years, Overlook had thought its slow turnaround to be a significant problem when clinicians see an average of 30,000 patients a year.
"The wait time was slowing everything down," Espinosa says. "If you can’t get a patient moved out on time, you can’t bring another one in."
A quality improvement team scrutinized the issue but never advanced beyond identifying and quantifying the problem, Espinosa says.
In 1995, the ED staff, fed up with declining satisfaction scores due to the dismal turnaround times, held a Patient Satisfaction Summit to search for a solution.
At the same time, a patient-focused care redesign team was tackling the radiology department. The ED staff saw the redesign as an opportunity to join forces and solve the turnaround problem.
A team was formed, and members began by gathering fresh data on the wait time. (See list of redesign team members, p. 90.) They tested 500 consecutive patients and calculated the average turnaround time to be 74 minutes. The team also mapped the process, looking for areas to streamline. The mapping work revealed the bottlenecks in the process. (See flowchart showing the process, p. 88.) For example, staff noted that when an X-ray was taken, it was sent with the chart to medical records staff, who would also pull every other film of the patient, regardless of relevancy to the current case. When this time-consuming task was completed, the entire package was sent to the radiologist to be read.
Different days, different ways
Adding to the overall complexity was that a different system was used on each of the three shifts during the week while yet another kicked in on weekends. If nothing else, the team wanted to come up with one system that could be used on all shifts on all days.
"It was a totally absurd system," Espinosa says. "It would get stuck upstream. We knew there had to be a better way."
Armed with its information on Overlook’s process, the team sought similar-sized hospitals with turnaround times of less than 30 minutes for plain films to serve as benchmarks. Tests such as ultrasounds and CT scans were excluded from the turnaround time monitoring.
"You stop annoying patients at 30 minutes," Espinosa explains. "At 15 to 18 minutes it becomes unexpectedly fast. That’s our goal."
The team talked with Harris Methodist Hospital in Ft. Worth, TX, and Fairfax (VA) Hospital. Based on what was learned from those facilities, they redesigned the process at Overlook.
Films now go directly to the emergency department and are hung for the physician to read. Often, as the tech is bringing the films in to the ED, he or she will catch the physician’s eye, and the physician will know the films are ready. The physician doesn’t have to continually check the bin for folders of films to read. The process also prevents films from being lost because they remain in one spot, hanging in the ED room.
While the films are hanging, the rest of the chart is pulled and combined with the new film. Eventually, the packet goes to a radiologist who will double-check the physician’s reading. If the physician has a question about the film that prevents making a diagnosis, the doctor will call the radiology hotline to order a STAT reading.
The change in process also included designating a tech position to be dedicated to the ED. Espinosa says who the tech reports to the head of radiology or the head of the ED doesn’t matter. Hospitals function equally well under both reporting structures, as long as the staff are held accountable, he says. At Overlook, the tech reports to radiology.
The accuracy of the readings has remained the same as under the old system, Espinosa says.
In the first month of implementation, December 1996, the wait time was slashed to 35 minutes. It continued to drop and now hovers between 23 to 26 minutes with a six minute deviation. (See chart tracking decreased wait times, above.)
Dealing with resistance
While the results of the change in process have proved beneficial, achieving them was not easy.
Some staff resisted the new system, explains Pat Treiber, CHE, MPH, who helped guide the departments through the redesign and change process. The key challenge of the redesign was negotiating with staff from two departments rather than one.
Here is her advice to help thwart turf wars, fears of losing control, and anxiety over the change:
• Everyone who is affected by the change must be involved with the redesign process.
"They need to have the ability to express their concerns on the issue," Treiber says. "You may not necessarily get consensus, but at least you’re getting things on the table."
• Arm yourself with benchmark data.
"You want to show them there’s a better place to be," she explains. For clinicians in particular, data can carry much more weight than a simple request for change.
• Stress patient satisfaction.
"It’s a big concern now, from the top administration down," Treiber says. "You want to tie in change with an improvement in satisfaction. It will increase the potential for buy in."
• Demand strong, supportive leadership.
"You need the leadership to bring the group through the process," Treiber says. "The group needs to know top staff want this change. When they see that it is going to happen and management isn’t going to back off it, they begin to accept the change."
• Keep meetings focused.
Treiber uses various tools during her meetings, which include discussing the current process, what’s working well, then moving on to what needs to be fixed. When a detractor tries to present a problem during the discussion, she intercedes to keep the team focused on positive results.
"You’re going to have some attempts at negativity. But you keep it focused on the process, not the people," she explains. "You keep everything objective that way, rather than subjective. That’s how you deal with the negatives."
When she first tried this method, she was surprised at how it set the tone for a positive, collaborative relationship among the team members.
"You end up talking about so many positives, the negatives become less significant," Treiber says. "By the meeting’s end, the team is excited about the new process. They’re talking, working together. You’d think they had been reborn."
[Editor’s note: For more information, contact James Espinosa, medical director, emergency department, Overlook Hospital, 99 Beauvoir Ave., P.O. Box 220, Summit, NJ 07902. Telephone: (908) 522-5310. Or Pat Treiber, Atlantic Health System, P.O. Box 959, Florham Park, NJ 07932-0959. Telephone: (201) 660-3154.]
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