Combining interim
leadership and process
optimization to improve the
ED patient experience

A 237-bed community hospital was struggling with a declining ability to meet the expectations of its primary market. Efforts to remedy community perception had a history of short-term gains that were never sustained. Throughput challenges robbed the facility of capacity and contributed to long wait times and poor perceptions of care.

As other facilities in the region began to feel the pressure of health care reform, this hospital faced an aggressive advertising campaign from regional competitors that focused on publicly reported metrics. The organization was also faced with a vacancy in the ED director position. They looked to Philips Blue Jay Consulting to help.

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Assessment

To understand the issues, a consulting team visited onsite and through observations, data analysis, and interviews with stakeholders and staff, obtained a solid understanding of the operational challenges and opportunities.

ED walkout rates were at 7% related to poor front-end processes, particularly a lengthy triage process. Numerous human resources had been applied to the problem as well as some process changes but improvements were not sustained. Door to provider times were the worst in the region at 147 minutes. Lengths of stay (both admit and discharge) were double established benchmarks

Approach

Based on the assessment, a project plan was established that focused on front-end redesign, streamlining of documentation, and improvements in the admitting process. Two consultants were utilized to support the project. One consultant focused on the process improvement activities, leadership development, and triage training. The other, serving as interim director, provided department leadership to support the needed changes. A new organizational structure was put into place with robust leadership development training for all existing ED leaders.

To design the process changes, staff-driven work teams were utilized. The Philips Blue Jay Consulting process improvement consultant facilitated the teams and guided the staff through the redesign process. Staff champions were identified and they assisted with the implementation. A different team was established for each improvement project and the efforts were sequenced such that staffing demands on the unit were tolerable and the pace of change was sustainable.

Project updates were provided at biweekly steering committee meetings that alternated with updates to the executive team. Metric performance was reviewed daily and posted in the department. The data was also discussed in pre-shift huddles.

Implementation

The teams implemented the following solutions:

• Nurse greeter and rapid registration

• Rapid triage by an RN on all ambulatory patients within 5 minutes of arrival followed by immediate bedding

• 100% bedside registration

• Triage documentation was streamlined thereby reducing the time to complete from 10 minutes to less than 1 minute

• Secondary triage if no beds were available, where a more in-depth assessment could occur and testing could begin on patients who were waiting for bed placement

• Fast Track criteria were established and use of space focused on keeping the patient vertical (use of chairs versus beds) and development of fast track sub-waiting area and results pending waiting area

• Development of admitting order sets to expedite the admission process

In addition to the process redesign, triage training was provided for all qualified nurses that included pretest, didactic training, posttest, and visual validation of skills and competency. Leadership development focused on advanced problem solving and team development skills.

Results

With the changes that were implemented, the following improvements occurred:

The leave without being seen (LWBS) rate reduced from 7.02% to 1.2% (83%improvement)
The walkout reduction generated an additional $5M in annualized net revenue
Arrival to provider was reduced from 147 minutes to 32 minutes (78% improvement)
Arrival to triage was reduced from 17 minutes to 4 minutes (76% improvement)
Arrival to room was reduced from 74 minutes to 14 minutes (81% improvement)
Overall length of stay (LOS) was reduced from 289 minutes to 201 minutes (30%improvement)

The length of stay reduction created capacity which will allow for a growth campaign to be established. The newly created leadership team was provided with the skills needed to maintain the performance as well as new problem solving tools that can be applied to future challenges.

Meet our team

Ricky J. McCraw, MBA, MHA, RN, CEN, FACHE
Principal
Philips Blue Jay Consulting

Rick has over 30 years of emergency, trauma, and physician practice leadership experience. He led a Level 1 trauma center ED and has reduced door to provider times, the decision-to-admit to inpatient bed times, implemented point-of-care testing in the ED, and streamlined nursing workflow and the ED discharge process. Rick is a certified nurse specializing in emergency nursing.

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* Results from case studies are not predictive of results in other cases. Results in other cases may vary

Combining interim leadership and process optimization to improve the ED patient experience