The c-suite’s ED optimization challenge

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The c-suite’s Emergency Department Optimization Challenge

This article was first published by Becker’s Hospital Review on October 21, 2016.
Hospitals are under regulatory pressure to reduce emergency department (ED) costs, improve efficiency, and increase throughput capacity, which ultimately impact hospital revenue and patient satisfaction scores. As such, the ED has taken on a more prominent role as it interfaces with every department of the hospital and healthcare system in some form, impacting the patient healthcare journey overall. These key factors are driving the urgent need for ED optimization.

Nobody is having a good day when they go to the emergency department. The goal of ED optimization is to improve performance and quality measures while enhancing the overall patient experience. However, implementing best practices is not easy when EDs are similar but not identical, and each day and each patient case has commonalties but is rarely standard.

Key metrics in delivering emergency care

While every ED may be different in terms of volume, physical structure, staffing, and community/population needs, the metrics for measuring its effectiveness are not. A key driver for optimization is addressing regulatory mandates and improving performance metrics, which include:


  • Left Without Being Seen (LWBS) – low LWBS rates increases revenue for most EDs, helps to reduce safety risks and supports positive community perceptions;
  • Arrival to Provider – a key metric that leads to early assessment and intervention, helps mitigate risk, and is a key patient satisfaction driver;
  • Length of Stay (LOS) for Discharged and Admitted Patients – an important metric for reimbursement and patient satisfaction as well as a key driver for increased capacity;
  • Decision to Admit – this metric reflects the ability of the ED to provide timely admission to an inpatient bed with standardized coordination, communication, and collaboration across all lines and is a key driver to HCAHPS scores;
  • Patient Satisfaction – largely based on the admitted patient’s overall experience, the ED processes can affect HCAHPS scores with about 60% of inpatients beginning their experience in the ED; and
  • Revenue Increase – implementing best practices and innovative processes that decrease LWBS and LOS metrics and improve the patient experience helps support increased revenue, more positive community perception, and potential growth for the hospital.

Three key steps for ED optimization

Data –in and of itself– is not the remedy nor does it provide the complete picture of an ED’s performance. To be effective, data must be combined with assessment, observation, and analysis of the ED and how the staff works within it. Information must be effectively integrated within the ED and across the hospital. The approach to optimization generally focuses on three key areas: 1) front-end flow, 2) back-end patient disposition and discharge, and 3) integrating patient experience strategies.

Step one: Improve the front-end flow

The first step in ED optimization is always to focus on the front-end process of arrival and triage/assessment. Triage is the process of rapidly assessing and sorting patients to provide the right care, in the right priority order, and with the right provider to have the most positive outcome. These processes are intense and require a high skillset to perform the process effectively and efficiently.

Managing triage acuity levels is of the utmost importance in delivering emergency care and is really the ‘art and science’ of emergency nursing. The goal of optimization of front-end efforts is to get the patient to the provider for care as quickly as possible. This optimization of the triage processes also decreases patient “walk-a-ways” so the hospital captures additional revenue by treating more patients overall, both those that will be discharged from the ED and those that may incur a hospital stay.
Case in point: Lower walk-out rates drive patient satisfaction and revenue1

A 408-bed community hospital with a history of high ED walk-out rates and multiple process improvement attempts to resolve the issues was failing at maintaining acceptable rates. The 68,000-annual-visit ED had tried a series of rapid improvement events (RIEs). The implementation of these initiatives was not consistent or sustained, resulting in minimal impact on LWBS and patient satisfaction.

Working with Philips, the hospital was able to greatly reduce arrival-to-triage times as well as improve arrival-to-room by 37% and arrival-to-provider by 44%. Subsequently, patient satisfaction rates increased 334% to the 100th percentile and the likelihood of recommending the ED increased 109% to the 88th percentile. Most importantly, the hospital was able to decrease LWBS by 41%, which generated over $1.2 million in collectable revenue annually.

Step two: Manage admission patient volume better

The second key step focuses on back-end processes from the decision to admit until the patient is placed in an inpatient bed.  Many hospitals struggle with limited inpatient capacity, hospital length-of-stays, and competition for the beds with higher ED and surgical/procedural volumes. As a result, emergency department crowding and boarding is common.

Several areas are critical to improving the ability to manage patient volume including more consistency with patient admission and discharge practices, coordination between the ED and other departments, and standardization of bed management. Process improvements can help increase access to available beds and streamline bed management processes in order to move patients through the ED and hospital more effectively.

Step three: Integrate patient experience strategies

The third step is the integration of the patient experience into all facets of the performance improvement efforts. This involves ED staff and provider education programs that focus on specific patient-centered tactics while increasing efficiency and effectiveness of care as well as enhancements to the patient environment.

It is important to first understand the patient’s journey in the ED and evaluate the clinical environment from a holistic perspective. Utilizing a data-driven and structured approach, healthcare providers can more readily pinpoint issues and begin to effectively align clinical workflows, technology, and resources to create long-term strategies for improvement.

ED optimization benefits

The patient experience in the ED has a significant impact on HCAHPS scores. There is research to support the correlation between the perceived care by an admitted ED patient and how that patient responds to his/her satisfaction survey once discharged from the hospital (American College of Emergency Physicians, Patient Satisfaction, June 2011). If the patient has a negative experience in the ED they will rate care lower, which is driving the c-suite to improve the patient experience in the ED. By equipping staff with the tools and support for respectful, informative interactions with patients, hospitals can increase patient recommendation and loyalty scores.

We invite you to read the second part in this article series at Urgent need for emergency department optimization
Read the article as published by Becker’s Hospital Review at The c-suite’s emergency department optimization challenge
Becker’s Hospital Review recently interviewed JoAnn Lazarus on performance improvement in the Emergency Department. Read the full interview here.

About our team

JoAnn Lazarus

JoAnn Lazarus, MSN, RN, CEN, FAEN

Principal and Practice Operations Lead

JoAnn is a leader for the emergency services team, providing interim leadership and leading process improvement projects. Among her accomplishments include establishing a fast track, a middle track, implementing a SWAT team for the waiting room, and decreasing the walk out rate by 25% in a 100,000-visit level 1 academic trauma center.
Will Stewart

Will Stewart, MSN, RN, CEN, EMT-LP, NE-BC

Consulting Principal

Will Stewart has decades of experience helping emergency departments increase efficiency and throughput capacity and boost patient and staff satisfaction, while lowering costs. He has assisted health care providers to reduce ‘left without being seen’ rates by as much as 80% and raise charge capture rates. Results have been realized by leveraging performance improvement best practices while providing focus on safe care for both patients and staff. Will brings a keen awareness to organizational and unit culture which is important when implementing sustainable change. With a focus on process and culture, Will excels at mentoring new leaders.
Ryan Oglesby

Ryan Oglesby, PhD, MHA, RN, CEN, CFRN, NEA-BC

Principal and ED Assessments Lead

Ryan brings 20+ years of clinical and administrative experience in pre-hospital, emergency, trauma, and critical care settings. He has helped clients reduce ED patient walkout and door-to-triage rates while improving patient experience.
Beth Fuller

Beth Fuller, DNP, RN, CEN, CCRN, CFRN

Consulting Principal

Beth has over 35 years of emergency, ICU, and critical care transport leadership experience in academic medical centers and community hospitals. She possesses extensive clinical and leadership knowledge and experience and has led ED change and reduced cost while improving patient satisfaction and employee engagement. Beth has assisted several organizations in redesigning their triage systems based on best practices, resulting in substantial decreased length of stay, decreased left without being seen rates, and improved patient satisfaction. She holds nursing certifications in critical care, emergency nursing, and flight nursing.

Urgent Need for Emergency Department Optimization

This article was first published by Becker’s Hospital Review on November 9, 2016.
Universally, the appropriate utilization and optimization of Emergency Departments (EDs) is a complex challenge.  The unpredictable nature of the ED and the chaotic, high-stress environment make best-practice improvements difficult to pinpoint or standardize. The lack of sufficient medical homes is contributing to patient volume increasing as more people are continuing to use the ED as the first place to go for care.

Increasingly, the ED has become the “front door” of the hospital and the 24/7-entry point for both the insured and uninsured with every ailment ranging from a life-threatening car accident or heart attack to gastroenteritis or a broken ankle.

The business of running an ED

When every second counts, improving ED efficiency is critical. Every hospital is focused on increasing throughput capacity to treat as many patients as they can as quickly and effectively as possible.  This is important not just from a patient outcome perspective but a hospital reimbursement and revenue standpoint as well.  Many EDs are based on a model that reimburses on metrics such as length of stay (LOS) and wait times for patients so they are incentivized to get patients in and out of the emergency department while meeting standardized national quality measures.

Beyond the key goal of performance optimization, some hospitals are extending the strategy of the ED to address larger value-based population health issues and strive to treat the patient in the most appropriate care setting from a cost standpoint.  The goal of these hospitals, ultimately, is to keep patients out of the ED from the beginning and have them go to a point-of-care setting that is more appropriate with their clinical situation such as a physician’s office or an urgent care center.  This approach requires a shift in focus from volume to value and must address nuances in particular population health issues.  Healthcare executives must consider how they can appropriately shift patients with minor issues such as a fever or limited injuries to a more appropriate setting effectively.

For the c-suite, this means thinking more strategically about the motivation of their particular ED and how it affects the larger hospital/health care system.  The answers to these questions require a thorough market and demographic analysis, insight and clinical expertise that are often found with the help of strategic partners to make data-driven decisions. Regardless if the hospital or system focus is volume-based or value-based, healthcare executives are dealing with similar issues around appropriate utilization of ED resources and determining what works best for their particular hospital, patient population, or region.

Urgent need for data-driven decisions

To improve ED performance metrics, hospital executives need to have access to meaningful performance data within the ED and other strategic departments and ensure the validity of the data to affect meaningful change. Using robust data analytics, hospital leaders can work with strategic partners to create a data-driven assessment and near real time metrics dashboard to provide high-level and detailed information on key performance metrics as well as identify areas that are performing well or require intervention. Data-driven decisions are essential to ED optimization and improving the key regulatory performance metrics by which EDs are assessed.

Case in point: Improve metrics, increase revenue

A 460-bed community hospital with a history of unsustainable success in process improvement was not meeting its ED expected performance and wait time targets.  The 48,000-annual-visits ED had previously tried to address the issues by developing a fast track program, followed by a model where a mid-level provider would initiate workups on select low acuity patients. Neither initiative took hold nor had the impact on flow that the organization sought.

Working with Philips, the hospital was able to better assess issues and collect relevant data to identify two major areas of opportunity: revising front-end processes and re-aligning staff resources away from a serial model of care.  Based on this critical data, the hospital was able to make key changes to patient care and flow.  As a result, the department realized significant improvement in arrival to triage (68%) and arrival to room (77%) as compared to their baseline.  Additionally, there was a 51% decrease in the number of patients who left the ED without treatment. The decrease in ED walk-a-ways generated additional collectable revenue of over $2 million annually for the organization.

The ED of the future

The emergency department of the future must be optimized from both the business side and the patient side and viewed not only within the ED but also as it compares or competes with other EDs outside of the hospital. To truly optimize performance, hospital executives must delve deeper into areas of discovery on utilization patterns, acuity patterns, and population trends over time. While patient volume may appear unpredictable in the short-term, if it is analyzed over time volume patterns can be more easily anticipated for the future. 

Looked at in this way, it’s clear that more insight can be revealed to further ED optimization. Many hospitals are enlisting strategic partners to help address these complex challenges, train on best practice recommendations, and support the implementation to sustain meaningful change.  As the ED becomes the new “face” of the hospital and strategic community partners, its overall success, its optimization and importance in delivering care cannot be overlooked.  With long-term sustainable transformation of the ED, healthcare organizations can regain potentially lost revenue while elevating the level of care and increasing patient satisfaction.

Read the article as published by Becker’s Hospital Review at Urgent need for emergency department optimization

About our team

JoAnn Lazarus

JoAnn Lazarus, MSN, RN, CEN, FAEN

Principal and Practice Operations Lead

JoAnn is a leader for the emergency services team, providing interim leadership and leading process improvement projects. Among her accomplishments include establishing a fast track, a middle track, implementing a SWAT team for the waiting room, and decreasing the walk out rate by 25% in a 100,000-visit level 1 academic trauma center.
Rick McCraw

Rick J. McCraw, MBA, MHA, RN, CEN, FACHE

Director, Client Development

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.
Ryan Oglesby

Ryan Oglesby, PhD, MHA, RN, CEN, CFRN, NEA-BC

Principal and ED Assessments Lead

Ryan brings 20+ years of clinical and administrative experience in pre-hospital, emergency, trauma, and critical care settings. He has helped clients reduce ED patient walkout and door-to-triage rates while improving patient experience.
* Results are rates measured prior to this engagement compared to rates measured at the end or after the engagement was completed. Results from case studies are not predictive of results in other cases. Results in other cases may vary.

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