D-to-D slashed 85% — in seven weeks!
ED manager, consultant, CEO a powerful team
The ED at Twin County Regional Hospital in Galax, VA, succeeded in cutting its door-to-doc time from 121 minutes to 19 minutes in just seven weeks — while annual volume was climbing from 19,000 to about 30,000 — by combining a process improvement plan designed by a health care consulting firm, the leadership of the hospital CEO, and the ED's medical director. The plan, which totally eliminated the ED waiting room, was implemented by Ryerson Management Associates in Akron, OH.
The consulting firm's initial assessment, begun in January 2009, indicated specific areas of need. "We had our physician and nursing consultant come in and look at quality of care, and both said it was very good," recalls Peter Ryerson, MBA, president and CEO. "We looked at patient satisfaction and felt it could be better, and most of that is built on turnaround time."
In the new process, patients who present to the ED are met by a greeter (usually an RN). "They stand at eye level to the patient and greet them the way our parents taught us: 'Good morning. What brings you to Twin County Regional Hospital today?'" he says. "They do a quick registration and bring them back to a room." Available rooms are indicated on a tracking board.
Hugh Jenkins, MD, FACEP, the medical director, says, "As they walk down the hall, the greeter uses our radio system to tell the doctor and nurse assigned to that room that they have a patient, and they provide the primary complaint. By the time they get there, the nurse is usually there."
If the nurse assigned to the room is tied up, he adds, the greeter nurse will start triage. "At the same time we put a chart with the room number in the doctor's slot," Jenkins says. "A lot of times everyone will get there at the same time."
Several services are provided at the same time, via the trauma model of care, Jenkins says. "Basically it is a team effort of coordination, where the patient is seen essentially simultaneously by the nurse and the doctor," he explains. "Sometimes the doctor will see the patient before the nurse, and sometimes the other way around, but the same services and documentation are completed by the end of the visit."
Patient satisfaction for the ED has improved from 74.7% in February 2009 to 81.7% in May 2009. The "true" current rating might be higher than that, argues Ryerson. "So many people have had poor experiences in the past, can still remember from what they experienced several visits ago, and may not rate the ED as it currently is," he explains.
The ED would not have succeeded in these efforts without a significant change in culture, not only in the department, but throughout the hospital, says Jenkins. While The Ryerson Group might have had its focus on the ED, the entire hospital had to be involved in making things happen.
Culture change is notoriously difficult to accomplish in a health care setting. How was Twin County able to do it, and so quickly? "When you move quickly, people do not have a chance to kick back," says Ryerson. "We told them they did not want be high on leadership's radar screen."
Speaking of leadership, Ryerson says "We got great leadership from the CEO, who was the change champion. If he says, 'We move,' they move."
In addition, notes Jenkins, there is a benefit in having an outside consultant involved in such cultural changes to "ride herd" on the staff. In fact, changes were made in every unit of the hospital, from room cleaning to lab and X-ray. "All those processes had to be examined. And Peter was able say to them, 'OK, how are you going to do this? What steps will you take to accomplish this goal?'" says Jenkins. "They had to write down the specific steps they would take and on what date the goals would be accomplished."
Through this process, for example, admission was streamlined. "All patients must be on the floor within 30 minutes of the decision to admit," Jenkins says. "That's unheard of!"
This admission deadline was accomplished with the implementation of several changes, says Ryerson. "First, we set up a system to identify when the room was vacant," he says. "We designed a system to get housekeeping to the room and have it cleaned within 25 minutes, and we then faxed the ED orders to the floor and transported the patient to the floor without any phone calls from the ED."
The following improvements were accomplished within four months:
- Laboratory tests for patients in the ED are all below 30 minutes from request (order by physician) to result.
- Results from diagnostic radiology procedures usually are received in 15-20 minutes.
- The environmental services department maintains the ED, with a level of cleanliness of more than 95%.
- For treat-and-release patients, the average time for arrival to discharge time has decreased from two hours and 50 minutes to one hour and 39 minutes.
Jenkins notes that Ryerson was able to counter the natural skepticism of the staff. "Even if the CEO had gone down personally to the lab, it would not have been as good as Peter coming in and saying, 'I've done this 50 times before,'" he explains. "When a staff member says something can't be done, and he says he's already done it, it's very hard to have resistance."
Sources
For more information on improving door-to-doc time, contact:
- Hugh Jenkins, MD, FACEP, ED Medical Director, Twin County Regional Hospital, Galax, VA. Phone: (276) 236-8181.
- Peter Ryerson, MBA, President and CEO, Ryerson Management Associates, Akron, OH. Phone: (330) 867-8800. E-mail: [email protected].
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