Patient Flow Solutions

Lean-driven improvements slash wait times, drive up patient satisfaction scores

Front-line workers take charge of process redesign, share responsibility for results

Who says change takes a long time to implement? Certainly not Susan Peach, MBA, BSN, a division chief nursing officer at LifePoint Hospitals, based in Brentwood, TN. In less than one year, Peach has led a successful effort to transform the flow processes at three different EDs, resulting in dramatically reduced door-to-provider times and double-digit hikes in patient satisfaction scores. Accomplishing this kind of transformation is never easy, acknowledges Peach, but she explains that resistance to proposed changes can be largely mitigated if ED staff actually design the new process and drive the implementation.

Relying on techniques borrowed from lean manufacturing, Peach first focused her improvement efforts at Sumner Regional Medical Center in Gallatin, TN, a 155-bed facility that sees about 28,000 patients in the ED every year. Then the improvement effort moved to Lake Cumberland Regional Hospital in Somerset, KY, a 300-bed hospital that sees about 40,000 patients in the ED annually, and, finally, Clark Regional Medical Center in Winchester, KY, a small, 100-bed facility that receives about 15,000 ED visits a year. "We have done small, medium, and large now, and had pretty similar levels of success with the process," says Peach.

For example, Peach explains that door-to-provider times, which were running in the neighborhood of 40-60 minutes, have been slashed to less than 15 minutes; patient satisfaction has risen by 20% to 40%; and patient volume is up by about 25% at each of the three facilities.

Plan for improvement

In each case, the improvement effort began with a three-day work session, a process referred to in the lean nomenclature as Kaizen. "This is really how staff and physicians redesign the process. You bring them all together, and there is a lot of training in lean tools and methods," says Peach. "But then this team — the actual workers in the ED — use a flow chart to [depict] the current process in the ED."

Once the current process is all sketched out so that everyone has a pretty good picture of how patients move through the ED, then staff look for those areas of down time when nothing is happening and patients are just waiting, explains Peach. This is when people become engaged in sharing ideas on how things could be done differently.

Typically, by the second day of Kaizen, the workers are busy coming up with a new process. "They are redesigning the way patients flow through the ED, so representatives from other departments [that impact patient flow], such as housekeeping, radiology, and lab, are invited to participate," says Peach. "They do have to commit to making significant change so that the overall goal is reached."

By the third day of Kaizen, the improvement team has a redesigned process and they are working on the details of a three-day pilot. At this point, administrators join the process because they have to approve the pilot, as well as any physical changes or costs that will be necessary to carry it out, explains Peach. "We do a pilot for three days because one day isn't good enough," she says. "Every day is different in the ED, so we pilot for three days, evaluate the results, make any needed changes, and then design a full implementation within 30 days."

Prepare to deal with non-compliance

While every ED is different, common themes emerged as the teams from each facility scoured their flow charts for opportunities for improvement. For example, all three hospitals eliminated steps at the beginning of the process that were slowing the process down.

"What happens in a typical ED is the patients are triaged in a triage room and then sent back out to the waiting room. Then registration staff do their work and the patients are sent back out to the waiting room again until they are called back for their medical evaluation," explains Peach. "In almost all of the redesigns, these steps were eliminated so that when a patient presents, he is brought back to a room in the ED, triage occurs there, registration goes to the patient, and then the physician comes in after that."

This type of realignment can be overwhelming and uncomfortable to ED staff who are used to their traditional way of doing things, so administrators have to be fully committed, says Peach. "Before you even start down this road, you have to decide what you are going to do with non-compliance, and everybody has to agree on this, because if you don't have a plan up front, and you have to face non-compliance, that can derail the whole process," she explains.

If one person decides that he or she is not going to change and gets away with that, then everyone else is likely to conclude that they don't have to change either, stresses Peach. "What we did [at each facility] was have an initial meeting with the [hospital] chief executive officer and the medical director of the ED, and we got commitments from them that they would not accept non-compliance," she explains. "We made it clear that we would work with all practitioners to make sure they understood that at the end of the day, we expected everyone to sign up and commit that they would do this. That is hard to do, but you have to do it."

Darrell Probus, RN, BSN, EMT, the director of Emergency Services at Lake Cumberland Regional Hospital (LCRH), acknowledges that three employees left the department within 30 days of implementing the new system because they were unwilling to go along with the required changes. One of the employees left on her own, but the other two had to be terminated. "I gave them written warnings and verbal warnings," he says, noting that these employees made it clear that they were not going adopt the new system no matter what. "I had no choice. They made the choice, actually. I just had to fulfill their needs."

Probus explains that there was a lot of skepticism that the new system would work at first. "Pretty much everyone, from top to bottom, said that they didn't see how getting patients to a bed faster and getting them in to see the doctor sooner would improve patient satisfaction," he says. In response, Probus says he challenged them to give the new system a try, and prove him wrong. "They [found out that] they were wrong. It took a lot of patience, and we had to stick with it."

Preach the team concept

While some patient-flow models tend to put particular pressure on charge nurses because they are ultimately responsible for connecting patients with appropriate care quickly, Probus says the process he has in place spreads the accountability around. "If one person has a bad night, everybody has a bad night," he says. "I really preach the team concept. Staff are tired of hearing me say the word team, but that is what we do. We work as a team together, and we get everything done together."

While there is nothing inherently difficult about working as a team, some staff have more difficulty than others adapting to it, and there are always challenges in any ED, he says. "I have always told [the ED nursing staff] that if they do what is right for the patient, I will always back them up," says Probus. "I appeal to their sense of why they became nurses."

Another tactic that gets a good response is telling staff that the patients who present for care are really neighbors, friends, and family, so they need to be cared for as if they are family. That gets the patient-centered care approach across immediately, explains Probus. There may still be some laggards who think they can continue to operate as they always have, but Probus has a response for them, too. "If you keep doing what you have always done, you will keep getting what you have always gotten," he says. "Every time you make changes, there is a little bit of discomfort. We are human beings, and we don't like uncomfortable feelings."

From the start of the improvement process, the ED physicians have been part of the team, and they have had an added incentive to move patients through the system more quickly because their remuneration goes up when they see more patients, says Probus. "We are increasing our census because we are catching people who used to just stop by to see if there is a crowded waiting room," he says. "We direct bed now, so these patients don't see a crowded waiting room, and there has been a snowball effect."

In 2011, the ED at LCRH saw a record 36,000 patients, and this year the ED is on track to see more than 40,000. In addition, Probus says there is more cohesion between the nurses and physicians than you generally see in a typical ED. "At first, the physicians were a little resistant to [the new approach] just like everyone else, but they have really come on board," he says.

Measure early and often

Probus's advice to other ED managers who are striving to implement change is to get ED personnel involved from the first day. "Get staff input, and get buy-in. That is what you've got to do," he says. "Then, if you can't get total buy-in, get staff to start making the decisions to make the process happen. That is how you get buy-in without even knowing you are getting buy-in. Let them take ownership of the process with you."

While staff ownership of the process is key, Peach emphasizes that any big change requires ample support from higher-ups. "Have a session with the senior leadership team first because they have to understand that this changes their world, too," she says. "In order for this to work, they have to round in the ED every day during the pilot and every day during the change, and to sustain the improvement they have to keep this up for quite a long time. The CEO, the CNO, and the ED manager are a big part of this."

To keep the focus on quality improvement, gather and disseminate data on a daily basis, advises Peach. "This is a major adjustment because we are all creatures of habit and we are accustomed to the old way of doing things. Major change occurred [for us] because we started measuring and timing everything," she says. "Everyone was acutely aware that patient safety and patient care were always [top priorities], but we also wanted to do this in a timely manner so that the patients were in and out as quickly and safely as possible."

Peach acknowledges that every hospital is different, and some personnel adapt more quickly to change than others, but when staff see that the patients are happier with the new process, they get on board.


Darrell Probus, RN, BSN, EMT, Director of Emergency Services, Lake Cumberland Regional Hospital, Somerset, KY. E-mail:

Susan Peach, MBA, BSN, a division chief nursing officer at LifePoint Hospitals, based in Brentwood, TN. E-mail: