Boost efficiency, patient satisfaction with staff-driven improvements

Zoning system, clinical teams foster accountability in the ED

When Robert Wood Johnson University Hospital in Hamilton, NJ, redesigned the ED to handle increasing patient volume back in 2001, its guarantee to see and treat patients quickly kind of "went by the wayside," explains Lisa Breza, RN, BSN, the hospital's chief nursing officer. "It's not that we weren't focused on [throughput], it's just that with increased transparency, value-based purchasing, and all these initiatives coming forward, we had a more focused review of our quality metrics and services that were rendered in the ED," she says.

However, administrators were determined to re-institute the guarantee, so they spent a year tracking data throughout the hospital to see where bottlenecks were occurring, and they deployed teams to redesign antiquated processes and steps that were taking too long. "We looked at the data and knew we wanted to improve both the quality of care and the service we provide," says Breza. (Also, see Management Tip on selecting team members, below.)

The quest for improvement continues, but in August of 2011, the ED was able to re-institute its 15/30 guarantee, informing patients that they will be evaluated within 15 minutes of arrival in the ED and they will receive a medical examination within 30 minutes, or the fees associated with these portions of the visit will be waived. The results from the initiative, thus far, include a decrease in the left-prior-to-medical-screen examination rate from 3% to 1%, with an average rate of 1.4% since implementation, in an ED department that sees 50,000 patients per year.

It's a simple guarantee, but backing up this pledge are hospital-wide improvements to patient throughput and a novel system of zones in the ED. Administrators say the system has made clinical teams more accountable for their work and delivered a more personalized experience to patients.

Take a whole hospital approach

While the improvement effort was keenly focused on the ED, administrators recognized that it needed to be a hospital-wide initiative. "You can't just improve ED throughput without improving efficiencies and throughput within the entire hospital," says Breza. "If our discharge process and our patient management processes are not streamlined, then we have increased length of stay in the main hospital, there are delays in getting patients treated and discharged, and we can't bring in new patients who are arriving in the ED."

Following the Lean approach to improvement, administrators assembled teams to look at different processes in the hospital and find ways to make them more efficient. For example, Breza led a team that looked at the admissions process to find out why patients from the ED were not getting placed into beds on inpatient units in a timely manner. "There were delays in nurses accepting report on patients, which caused bottlenecks in the ED, as well as delays in the ICU and our telemetry units," she explains.

To get around this problem, the team developed rules and procedures that give ED patients priority, so that nurses will take report on these patients unless there is something critical going on in the unit, says Breza. "There is no excuse not to take report, and if a nurse is not available, the coordinator on the unit will take report and get that patient up on the floor in a timely fashion," she says.

To insure that such policies and procedures are adhered to and that everyone is on the same page, administrators hold bed huddles twice a day, at 7:30 in the morning and 3:30 in the afternoon. "We review what kinds of patients we have in house and what kinds of admissions are waiting; we look at the whole hospital and what is going on in all disciplines," says Breza. "This way, everyone knows what needs to be done for that day, and they all go back to their areas with a goal of prioritizing throughput."

The team also discovered that some ED patients weren't getting transferred to inpatient beds quickly because there was no transport available, so the team assigned dedicated transport to the ED, says Breza.

Use zones, care teams

Big changes in the ED included a revamped quick triage process that involves retrieving minimal information from a patient upon entry, so the patient can be seen by a provider quickly, and division of the ED into four zones, each manned by provider teams. In three of the zones, a physician, two nurses, and a tech work together to take care of patients; the fourth zone is a prompt care area overseen by a physician, a mid-level provider, two nurses, and a tech, explains Eileen Singer, DO, FACEP, FACOEP, chair of the Department of Emergency Services.

"Each team is working close to where the patients are being treated, which is better in terms of patient satisfaction and throughput because the providers are not walking back and forth to different areas of the ED," says Singer. "We have also put our supplies in certain strategic areas that are commonly used in the department so that they are readily available for treating patients."

There were a few speed bumps involved with getting the zoning process implemented, acknowledges Singer. "When you have a group of physicians who just randomly see patients, there are some who are faster than others," she says. However, when patients are being assigned to a particular zone or team, providers have a responsibility and an obligation to see those patients quickly, she says.

"In the beginning, more patients were being brought back [into the zones] and it was difficult because some providers were getting overwhelmed in their zones," says Singer. "But I think it forced everybody to be more accountable and to work as a team."

For example, when one nurse is busy, the other nurse working in the zone will pick up the slack and help out because the team is responsible for a specific set of patients, explains Singer. "You have to have a good working relationship with the other people in your zone in order to move the patients through," she adds.

Do detail work, analysis prior to implementation

It took some tweaking before the system worked well, notes Pam Ladu, the hospital's executive director of strategic planning and operations improvement. "We had to get feedback, make some quick changes, and reevaluate it until we got it to the point where it was more streamlined and everyone was comfortable with it," she says

For example, when the zoning process debuted, there was some confusion during the morning hours because the prompt care area opens later than the other zones. As a result, patients were getting backed up in one zone — which was not the intent, says Ladu. "The physicians and nurses who worked on that team were getting bombarded, and they were not too happy about it," she says. However, appropriate adjustments were made to alleviate the stress on the system and to keep patients moving.

"It involved a lot of work on the part of the clinical coordinator, who is the person who is really looking at the acuity of patients and determining which zone they will be assigned to so that no one team gets overloaded," says Singer, noting that these decisions are made immediately after the quick triage process.

Further, getting the process to work efficiently required a lot of detail work in the background, adds Ladu. "Before we implemented any of this, we had to really analyze the data in the ED and look at what our peak times were, when patients were coming in, and when they were beginning to queue," she says. "And we had to make sure that staffing was appropriate."

However, in just a few months, the approach has already carved five minutes off of the median room-to-medical-screening-exam time, which now stands at 16 minutes.

Delegate change process to ED clinicians, staff

As with the other changes made throughout the hospital, the zoning system was developed and implemented by a team. In this case, physicians, nurses, technicians, and other personnel from the ED drove the process, and this was key to the ultimate success of the approach, stresses Singer. "This is very important because you want buy-in from the people in your department," she says. "When there was some pushback, there were a couple of nurses [from the team] who would encourage people to give it a chance, so you need champions for these types of projects."

Of course, problems still arise, and there can be unanticipated surges. However, to ensure that each of these issues is dealt with expeditiously, there is always a designated lead physician who works with the coordinating nurse to keep throughput moving, explains Singer.

"The zoning system is one of the better processes that we have put into place," she says. "It definitely decreases throughput time and it increases patient satisfaction because the patients and their families see the physician right there. They know who the physician is because [he or she] is in close proximity to the patients."

In addition, it enables physicians to regularly round on their patients because they are all in a concentrated area. "Everyone works together, they know their patients, and they know they are with this team for the day," she says. Overall care provider satisfaction has risen from the 75th percentile in 2010 to the 80th percentile in 2011, according to Press Ganey surveys.

From a "Lean" perspective, the zoning methodology reduces non-value-added time and increases value-added time, says Ladue. "For the patient, it creates more time with care providers and less time spent searching for supplies or running all over the place," she says. "So in addition to making everything more efficient, it enables patients to have more face time with the people they think are in charge of essentially getting them home sooner."


  • Lisa Breza, RN, BSN, Chief Nursing Officer, Robert Wood Johnson University Hospital, Hamilton, NJ. Phone: 609.584.6582.
  • Pam Ladu, Executive Director, Strategic Planning and Operations Improvement, Robert Wood Johnson University Hospital, Hamilton, NJ. Phone: 609.584.6582.
  • Eileen Singer, DO, FACEP, FACOEP, Chair, Department of Emergency Services, Robert Wood Johnson University Hospital, Hamilton, NJ. Phone: 609.584.6582.

Management Tip

When assembling a team to drive change, include some members who tend to resist new ideas

One common approach to problem solving is to assemble a team of employees or clinicians who are impacted by a specific issue or problem. The team members first sort out all the factors involved and then devise a solution. The team can then also be responsible for implementing the solution with colleagues. It's a strategy that Robert Wood Johnson University Hospital in Hamilton, NJ, is using in a hospital-wide, performance improvement initiative.

Interestingly, Pam Ladu, the hospital's executive director of strategic planning and operations improvement, suggests that when selecting individuals to serve on a team, it is not necessary, or even advisable, to always select people who adapt easily and eagerly to new ideas. To the contrary, it can pay off to include people who are often resistant to new approaches. "Those are the hardest minds to change, so if they are part of the change, they are more likely to adapt to it and spread that good feeling to their peers," she says.