System-wide flow initiative slashes patient wait times in the ED, boosts volume by 25%

Patient-centric care at the heart of new approach

Process improvements typically take center stage whenever hospital administrators decide that patient throughput and patient satisfaction are not where they need to be. But moving the needle in a positive direction will be slow-going, if not impossible, if there are larger problems in the work environment. That, at least, is what Assaad Sayah, MD, chief of Emergency Medicine at Cambridge Health Alliance (CHA) in Cambridge, MA, discovered when he was brought in to the organization in 2006 to conduct a major overhaul.

Not coincidentally, 2006 was the year health reform was implemented in Massachusetts, and administrators were worried about the law's impact on safety-net facilities. "They felt there needed to be an improvement in the patient experience across the board because if all of a sudden a lot of patients had an insurance card, they would have the choice to go anywhere they would like, and they may not come here," recalls Sayah.

At the time, volume was dropping at CHA's three facilities, patient satisfaction was among the worst in the state at CHA's Cambridge facility, and relationships with the prehospital community clearly needed work, says Sayah. However, multiple efforts to improve the patient experience had resulted in little to no gain. "The administration realized that there needed to be something more drastic happening, so I was recruited to lead those changes in the ED," he says.

Make sure staffing, compensation are reasonable

Even though CHA's facility in Cambridge is a safety-net hospital, it is a Harvard teaching hospital, so physician recruiting shouldn't have been a problem, says Sayah. However, in 2006, Sayah found that there were chronic physician vacancies. "I just couldn't understand why a hospital in this location with this reputation and affiliation would have any kind of difficulty," he says. "But there were good reasons why that was the case."

Sayah discovered that the physicians were being compensated at less than the 20th percentile for the market, and the emergency physicians were expected to do much more than emergency medicine. "People who are trained in a discipline want to practice what they are trained to do, not more and not less. But for various reasons historically, at two or three [CHA] campuses, the ED physicians were writing admitting orders for admitted patients, which is an inpatient service, and responding to inpatient services to take care of patients," explains Sayah. "You are not going to be able to recruit and retain quality physicians with that kind of compensation package and scope of practice."

Consequently, even before he signed a contract to come to CHA, Sayah received promises in writing from the organization that physician compensation would improve and that he would have the opportunity to improve the work environment and the scope of practice for physicians.

There were also problems on the nursing side. While compensation was reasonable for the market, the EDs were chronically under-staffed, says Sayah. "We found that, based on national benchmarks, our EDs were staffed at about the 20th percentile, so we were under-staffed, based on our volume," he explains.

To correct the problem, Sayah worked with staff to prepare a proposal that would bring nurse staffing up to the 40th percentile. "It was halfway through the budget year, but I wasn't going to wait six months to start making these changes because you need to have the right ingredients to build on to improve your flow," he says. "You need to have the right physicians and the right staffing."

Put patients at the center of your process

It took two to three months to implement the staffing and compensation changes, but once they were in place, Sayah turned his attention toward co-chairing, with the chief nursing officer at that time, a system-wide flow initiative that included all disciplines and all three hospital campuses.

There were multiple problems with the existing system, but Sayah says chief among them was the fact that patients had to move constantly around the providers, going from one place to another with multiple waits in between the stops. It was like going to an amusement park where you have to continually stop and wait to get on the next ride, recalls Sayah. So he endeavored to replace this approach with a system that put patients at the center, with the providers moving around the patients. "We really spent a lot of time re-thinking the process without spending a lot of money or increasing our footprint," explains Sayah. "The work was done using the same resources we negotiated [during the earlier steps] to make sure we were at least at the 40th percentile in staffing."

The only additional expense involved in the initiative was the creation of a new position within the ED called a patient partner. "This is a non-clinician who is the first person a patient encounters when he walks into the ED," says Sayah. "The patient partner's job is to smile, be helpful, and to answer questions. The patient partners are multilingual, and their training is in customer service."

Under the new process, when a patient first enters the ED, he or she will be greeted by a patient partner, who will ask for three pieces of information: a name, either a social security number or a date of birth, and the chief complaint; the patient partner will then quickly register the patient and bring him or her immediately back to a room, explains Sayah. "If a rapid assessment room is available, the patient will go there. If a rapid assessment room is not available, but there is a room available in the main ED, the patient will go there," he says.

While the patient partners do not have medical training, they are empowered to immediately bring a patient into the main ED if that patient does not look well or is experiencing problems such as chest pain or difficulty breathing. "They put the patient in a wheelchair without asking any questions, and he or she is brought into the main ED, bypassing rapid assessment," explains Sayah.

"The way patient partners know where the rooms are is they have computer access to our tracking board. They know the rooms that are available in the whole ED, so that takes care of that whole first step," adds Sayah. At two of the three CHA campuses, patient partners are on staff 12 hours per day, and there is 16-hour per-day coverage at CHA's busiest campus in Cambridge.

To eliminate bottlenecks, streamline care process

Where triage used to take place in one room with one nurse, creating a bottleneck with a queue of patients lined up, there are now three nurses and somewhere between 5 and 14 rooms available, depending on the campus. "There is no bottleneck anymore," adds Sayah. "If at any time the nurse gets to a point where she feels a patient is too acute for rapid assessment, the patient will be moved right away to the acute side [of the ED]," notes Sayah.

However, for the less acute patients, the Emergency Severity Index (ESI) 4s and 5s, the nurse will continue with triage and she will also handle the nursing assessment. This is in contrast to the way things used to be done. "Historically, the nurse would do triage, then the patient would go back out into the waiting room. Then at some point, the patient would come back into a room and another nurse would ask the same questions all over again," explains Sayah. "Now it is the same nurse doing triage, the nursing assessment, and care in rapid assessment."

Further, if the physician assistant on staff in rapid assessment is available, he or she will join the nurse while she is collecting clinical information so that the patient only has to provide information one time to everyone. Nancy Sears-Russell, BN, BSN, MS, associate chief nursing officer, Emergency Services, at CHA, acknowledges that many nurses have difficulty making the adjustment to this type of process. "A lot of them have a hard time with this because they don't want the provider in the room until they are done with the patient, but that creates waiting time for the patient," she says. "They have to make adjustments, and to be sensitive to each other's work."

Also, at some point during this phase of care, a registration person will come into the patient's room to complete the registration process. Then providers will continue with any treatment or care of the patient that is required, and the patient will be discharged. The new approach has delivered significant dividends, trimming the average LOS from three hours to just over an hour for rapid assessment patients, says Sayah. "Now, 97% of our patients are in a room within five minutes, and over 90% of them are seen by a provider within 14 minutes of arrival," he says.

Match resources to patient needs

The transformation in emergency services at CHA has been so successful that visitors from other health care organizations stop by at least twice a week to learn how they might implement similar changes. Sayah is adamant that change on this scale is not possible without strong institutional support. "I don't care how good you are in the ED, you are not going to be able to get to this level of efficiency without everyone in the institution buying in and giving you a hand," he says.

Sayah says he was fortunate that CHA administrators were already on board and looking for a change agent when he joined the organization. "The system was ready for change, and the change came like a tsunami because we changed everything in all three EDs simultaneously in a span of 2.5 years," he says. "Prior to [my arrival] the system had probably had no change for 25 to 30 years."

With the improved efficiency, volume at the three EDs has increased from 77,000 patients per year in 2005 to close to 100,000 patients per year today. And the leave-without-being-seen (LWBS) rate has been slashed from 4.5% to 0.6%.

At its heart, Sears-Russell says the new process is about matching resources with patient needs. "Patients who are at ESI triage level 4 or 5 should have a very short LOS because they don't need much. They may have a sore throat, an ear ache, a small cut on their finger, or an X-ray that is normal," she says. However, Sears-Russell stresses that many EDs still make these patients wait behind the patients who need multi-hour-long workups. "With our approach, all patients get into a room right away, the nurses and the providers see them at the same time right away, and then they are out the door."

Sears-Russell says she sees too many ED administrators pointing their fingers at other departments or tinkering around the edges rather than thinking through what changes are really needed to get a different result. You have to look at patient flow from the perspective of the patient, and eliminate long waits as an option, she says. "Some people try to come up with reasons as to why a patient should wait when there is a room available," she says.

What's required is a wholesale change in culture, says Sayah. "The new culture is that the patient is in the room, and we are going to move around that patient," he says. "The nurse will come in, the doctor will come in, and registration will come in, whereas before the patient was moving around us."

Sources

  • Assaad Sayah, MD, Chief of Emergency Medicine, Cambridge Health Alliance, Cambridge, MA. E-mail: asayah@cha.harvard.edu.
  • Nancy Sears-Russell, BN, NSN, MS, Associate Chief Nursing Officer, Emergency Services, Cambridge Health Alliance, Cambridge, MA. Phone: 617-665-1000.