ED redesign improves patient flow, satisfaction

Lean project involved entire hospital

Just eight months after Sycamore Medical Center emergency department in Miamisburg, OH, launched a Lean project to improve patient flow in the emergency department, the percentage of patients who left without being seen dropped dramatically and the department’s patient satisfaction scores rose to the 90th percentile.

In December, the emergency department achieved the 96th percentile on patient satisfaction surveys, the highest among the hospitals that are part of Kettering Health Network. Scores are in the 97th percentile for patients’ perception of how long they wait for treatment, the 96th percentile for helpfulness of the staff, and the 98th percentile for waiting time for a room, says Dee Guttadore, MHA, RN, clinical nurse manager of the emergency department.

In January 2011, the hospital contracted with an outside firm to work with a multidisciplinary committee to develop a Lean project to improve the patient flow in Sycamore’s emergency department. The committee included emergency department nurses and physicians, hospitalists, two managers from the acute care floors, and representatives from case management, the laboratory, radiology, bed control, registration, and environmental services.

“We analyzed how patients arrive at the emergency department, how they are triaged and treated, and how they are admitted. We included all disciplines so everyone involved would understand the ‘snowball effect’ that one department can have on another at slowing patient flow throughout the hospital,” she says.

The emergency department is one of a handful of departments where every aspect is data-driven, Guttadore points out. “The emergency department staff must be experts in time management and prioritization. Every aspect of the emergency department is managed by time: the amount of time from the door to triage; triage to room; room to doctor; doctor to disposition. We strive to achieve a three-hour or less stay for patients being released, but to a patient, even a two-hour wait is like a decade,” she says.

The team examined the roles and responsibilities of the entire emergency department staff, then rewrote the job descriptions for everyone, being explicit about what the exact roles and responsibilities were.

“We determined that some staff were doing a lot of work while others were running around the department,” Guttadore says. For instance, the team asked the emergency department secretaries to wear pedometers and found that they were walking an average of six miles a day. “They were dropping off papers, bringing patients back, and performing a lot of tasks. If the secretary wasn’t at the desk, the nurses were answering the phone instead of performing patient care,” she says.

“We told them that if they were walking to the other end of the department, someone else was doing their job. It was enlightening to them to realize why it was important not to have a nurse, with a lot of training and a professional salary, answering the phone,” she says.

At the beginning of the project, in January 2011, 4% of patients were leaving without being seen by the emergency department physician. By the end of August the figure had dropped to 0.04%. “In addition to being a patient care problem, we looked at the loss of revenue for those patients walking out and seeking treatment elsewhere,” she says. For the past 18 months, the hospital’s rate of people who left without being seen is less than 1%. When the project began, the emergency department’s patient satisfaction scores were in the 70th percentile. Now it’s consistently in the 90th to 96th percentile and in August 2012, the emergency department’s patient satisfaction score was 99%.

The project also reduced the average door-to-doctor time as well as length of stay in the emergency department. During the second year, the team worked to improve the relationship between the emergency department staff and the hospitalists. “In order facilitate patient movement from the emergency department, we need to have hospitalists available to accept them,” she says. The multidisciplinary team created a set of orders the hospital can use if the patient is stable and can go to the floor. The orders include only the care essential for the patient when he or she arrives on the floor. Now that the organization has established an electronic medical record, the hospitalists are using the brief orders more frequently to expedite the transfer of patients, she says.

Case managers cover the emergency department from 9 a.m. to 9 p.m. and work with physicians on medical necessity and appropriateness of care and talk with families when patients don’t meet inpatient criteria. “All of our case managers are experts at expediting appropriate admissions and facilitating patient discharges that in turn will lead to freeing up beds for new patients,” she says.

At Sycamore Medical Center, bed control is part of the emergency department, an arrangement that helps with timely transfers of patients from the emergency department to the floor. To facilitate speedy transfers of patients, Guttadore meets regularly with the inpatient nurse managers. “When one department doesn’t understand the flow of the other, frustrations mount. Clearly communicating with managers and staff and providing thorough explanations from the emergency department inspires resolution from both departments. I was an inpatient floor nurse for 20 years and I feel I have a strong understanding of the concerns of both departments,” she says.

The inpatient floor staff sometimes work in the emergency department to learn what the staff are up against. “They learn first-hand what it’s like to have 20 people in the waiting area and having to leave a sick patient lying on a stretcher on a four inch-mattress and having to share only two bathrooms with 26 other patients,” she says.

As part of the project, the hospital switched from a portable telephone system to walkie-talkie units for staff and physician communication. “It’s much quieter now. The noise level is frequently a patient complaint,” she says. They analyzed the space and moved an oxygen storage unit and some rarely used file cabinets, freeing up considerable space for items such as new computer stations for hospital residents to use.