Unique collaboration targets delays: Learn from the impressive results of 31 EDs
A landmark collaborative pools the resources of 31 EDs with the goal of reducing delays
Reducing waits and delays is critical to improving outcomes in emergency departments (EDs), emphasizes James Espinosa, MD, FACEP, FAAFP, chairman of the department of emergency medicine at Overlook Hospital in Summit, NJ. "It can save the lives of patients with heart attacks and strokes and can affect patient satisfaction, costs, and quality of life for our patients and our caregivers," he says.
The Boston-based Institute for Healthcare Improvement (IHI) recently took on that challenge with a unique collaboration. Thirty-one EDs began an intensive, seven-month effort in April 1998 to reduce delays and cycle times, with the goal of achieving improved health care outcomes, more timely service, and higher levels of patient and family satisfaction.
"There is a tremendous strength in these 31 hospitals working on a total of 93 projects, which were able to communicate and support each other," notes Espinosa, who served as co-chair of the collaborative.
A planning group provided structure and leadership. "The planning group has the experience and the knowledge to mentor and coach the 31 teams through, from the start of the work to completion," says Espinosa.
Each ED was required to have a physician, nurse, and administrator as participants. An operational cycle time, including fast track, admissions, ancillary services, bedside registration, and triage, was chosen by each team.
However, a clinical process was looked at first, such as time to thrombolytics or antibiotics, pain management, time to completion of CT scan for stroke patients, asthma care, and admission of psychiatric patients. "You need to start with a project that everyone is willing to work on," explains Linda Kosnik, RN, MSN, CEN, unit manager for the ED at Overlook and co-chair of the collaborative. "It's easier to get staff buy-in by reducing a clinical process first because that is related to patient care, which is the reason they work in health care."
Administrators open to new approaches. Too often, obtaining administrative buy-in to reduce delays is an uphill battle, reports Espinosa. "I suspect it's even more difficult now than in previous years, because hospitals have less resources. EDs are truly areas that have been underresourced, more so since the managed care movement," he notes.
But administrators who are concerned about patient satisfaction are taking a second look at delays in the ED. "Attitudes are changing," Espinosa says. "Administrators are beginning to realize they have to pay attention to the fact that patients want prompt care. They are starting to listen to innovative approaches which they had never considered before."
The IHI project emphasized changes to benefit both the ED and the hospital. "Senior leaders want to improve patient satisfaction, and so do we," says Espinosa. "The inefficiencies of EDs have ground us down, both individually and collectively, and have shortened careers."
Linking delays to specific outcomes is the way to sell this concept to administrators, says Espinosa. "There are four possible outcomes to measure: medical, cost, patient satisfaction, and quality of life," he explains. "Demonstrate that delays of a clinical nature can increase costs, decrease patient satisfaction, and reduce the quality of life for patients and our own staff."
To reduce delays, the ED needs support from administrators and other departments, argues Espinosa. "In the average American hospital, there is still too much of the attitude 'ED go fix it,' as if it was a separate entity, and far too little 'How can we improve this process together?'" he says. "But administrators are finally starting to share the responsibility of outcomes improvement with the ED."
The ED doesn't stand alone. The project emphasizes the ED's role as part of a larger system. "The ED is not alone in this. That concept is a major paradigm shift for ED managers," notes Espinosa. "For some hospitals, this was the first time a senior manager heard about the problem of delays, or listened to credible experts hold forth on the debilitating impact that these inefficiencies are having on the hospital. If you want changes in the ED, you must be willing to commit to change in the entire hospital."
The Cardiology Advisory Board in Washington is making the ED a priority on its agenda, reports Espinosa. "They are now suggesting expansion of EDs, when just a few years ago the idea was promoted that under managed care EDs would become less important, with less volume," he says. "Think tanks are now preaching to administrators that their EDs are perhaps the most important link to reducing inefficiencies and delays."
Use data to show the ED isn't to blame, says Espinosa. "Data is very helpful when you are making the case in front of senior management that delays aren't all the ED's fault, that, in fact, they involve the entire institution," he explains. "That acknowledgment creates an instant sign of relief, and an extraordinary removal of burden on the shoulders of ED managers."
Sharing experiences with colleagues was key, says Espinosa. "Being an ED manager can be a lonely, difficult position filled with perils, where the challenges are big and the payoffs appear small and uncelebrated," he notes. "It's liberating for ED managers to hear they are not alone in having these problems, that everyone has the same struggles and utter frustration with the old style of change management."
The project required administrators to invest time to confront delays. "Before, managers might have had one meeting a month, where they talked about the problem for 10 minutes," Espinosa says. "This was an opportunity for ED managers and senior leaders to sit in a room and work with each other, so results can be achieved."
ED managers often have excellent ideas for reducing delays, but a lack of support may keep those ideas from coming to fruition, says Espinosa. "There is no shortage of ideas, but how do you implement them, how do you get others to believe in them?" he asks. "During the IHI project, we provide ideas, coach them through interventions, and strategize in ways likely to create change."
Part of the project's focus is putting things under the control of the ED. "ED managers need to think outside a victim mentality," says Espinosa. "We've moved the arena of bed control under the ED, and have radiology techs reporting to the ED. Hearing about those kinds of experiences allows others to think out of the box."
For multi-hospital systems, bringing ED leaders together was significant. "Even though we are an eight-hospital system, the opportunity for our EDs to exchange data was actually very limited," reports Wendy Tuzik Micek, DNSc, RN, director of care management at Advocate Health Care in Oakbrook, IL. "Our organization ended up being our own mini-collaborative. We have begun sharing data very openly, problem solving politically, and breaking down barriers that previously existed."
Sharing information with competitors was not a problem. "It's all too common that those hospitals and EDs who are geographic neighbors but are competitors have a built in inhibition to full sharing and collaboration to improve the quality of life for their community as a whole," says Espinosa. "Some participants might be competitors, but in this environment, away from town, in casual clothes, those barriers break down and there is a sense of kinship."
Link patient satisfaction to delays. Patient satisfaction is directly related to reduction in delays, says Kosnik. "Most consultants say if you are nicer, you will see patient satisfaction go up, but we believe it's directly linked to delays," she explains. "If a patient is waiting, it doesn't make any difference how wonderful the staff is. That patient is still going to be angry."
Overlook's ED has demonstrated this link, says Kosnik. "After we reduced delays significantly, we've been in the 100th percentile for three months in a row now," she reports. "Our ED and the institutions we benchmarked with have proven that reducing delays made a difference."
Many EDs in the collaborative are tracking patient satisfaction using such surveys as Arbor, Gallup, Parkside, and Press Gainey. "Some organizations have already begun to see improvement in their scores after the first four months of the collaborative, and others are expecting improvement based on the changes being made," says Kevin Nolan, a Silver Spring, MD-based statistician who worked on the collaborative. (See Overall Patient Satisfaction chart.)
Before delays were reduced, Nash General's ED averaged 11 complaints a week. "When delays dropped last fall, we went three weeks without a single complaint," says Michael Clark, RN, nurse manager at Nash General Hospital in Rocky Mount, NC. "We used this data to show our administrators that our primary patient complaint is due to waits."
Here are some key points of the IHI project:
Don't reinvent the wheel. "Start with data that is already benchmarked, so staff has clear goals," says Kosnik. "For example, one of the mandates of the Heart Attack Alert Program is that time to thrombolytics should be less than 30 minutes."
Use a consistent set of parameters. When comparing times with other EDs, make sure you're not comparing apples with oranges. "Ask them what they mean by admission time, to be sure you are measuring the same thing," says Kosnik.
When one ED in the collaborative claimed to have reduced admission time to three minutes, listeners were shocked. "But it turned out they had a different definition of admission time," says Kosnik. "They weren't talking about the time the patient is admitted until they leave the unit. It turned out their concern was the time the patient left the ED until they got upstairs, because they had an elevator problem."
Realize how different processes impact one another. Cycle time is a symptom of a larger problem, not the disease itself, says Kosnik. "For example, reducing x-ray times significantly impacts on your fast track times," she explains. "If you want a fast track function under an hour and your x-ray times are 90 minutes, you can't do that."
Collaborate with nurses and physicians. The planning group included co-chairs from nursing and medicine, notes Espinosa. "It's very rare to have that kind of collaboration, and that was a very important point to make," he says. "There are very bright groups of emergency physicians with extraordinary leaderships, but if they cannot collaborate with nursing, they can't move systems."
Break down processes into components. "Identify your most burning problem, and break it down into pieces you can work on," advises Kosnik. "If you just try and fix the entire problem, it will take forever to see results."
To break the problem into components, use a process your staff is already familiar with, such as the National Heart Attack Alert Program four D's (door, data, decision, and drug). "The same components can work for any process," says Kosnik. "For example, with antibiotics, the 'door to data' would be the time it takes to get the patient an x-ray and it shows they have pneumonia."
An operational process like admission can also be broken down into components. "You can track the time the patient is admitted, when a bed is requested, when the bed is assigned, and the time the patient actually leaves the unit," says Kosnik. "This helps identify your issue. If your problem is giving report, include that in your baseline data."
Emphasize to administrators that a minimum of capital investment is required. Reducing delays doesn't require significant financial investment, Kosnik stresses. "Everything we do is cost effective. It doesn't require big budget expensive equipment, redesigning the ED, or additional staff, just reorganization," she says.
Collaborate with other departments. "You must be willing to work together," Kosnik stresses. "When we reduced time to thrombolytics, we learned that having the physicians, nurses, and cardiologists working together as a team created a synergism. It also works the other way, if you don't have one of those groups on board, you won't accomplish anything."
It's almost impossible to succeed without administrative support. "If ancillary services such as lab, pharmacy, x-ray, and respiratory therapy aren't working with you, it sometimes requires a heavier hand," Kosnik notes.
When Nash General's ED reduced delays in identifying and treating asthma patients, respiratory therapists were invited to meetings and asked for their input. "You can't impose your will on outside providers, they have to be part of the team," says Kirk Jensen, MD, medical director of the department of emergency medicine. "We asked the radiology techs how we could make their lives less complicated, so they identified with the global mission of improved patent care."
Show cost savings linked to reductions in delays. "A key cost outcome of the reduction of delays is an increase in the volume of patients seen without having to increase staff," says Nolan. "Some organizations located in vacation areas are already experiencing this benefit. Other cost measures tracked by EDs in the collaborative are ambulance diversion hours and the number of patients leaving without being seen."
Track delays as they occur. Overlook's ED uses a tracking system that monitors six parameters. "One of the main problems is deciding when to intervene," says Kosnik. "If the time to see a physician is going up, it may not mean the physicians are slacking off. It is a common indicator of how an ED is doing overall. The tracking system can reveal if you are backed up because of admissions, x-ray, or patient acuity."
The system tracks wait times in 15-minute intervals. "If it goes above the mark for three 15-minute intervals, we take action, such as calling for another tech," says Kosnik. "This way, we can intervene when it gets backed up, but before you get out of control."
A wall board can be substituted for a tracking system, suggests Kosnik. "You can use a wall board with five magazine racks. Each row of charts can stand for different things, such as waiting for physician, waiting for discharge or consult, or observation,"she explains. "The charge nurse can look at the board and clearly see that there are three charts in the physician rack but eight patients waiting for admission."
Allot for resources needed to complete the project. "These projects don't get done on their own. They have to be supervised and coached and managed," says Kosnik. "Everybody is busy, and it usually involves some tedious work, such as data collection. Consider the resources you need at the onset of the project."
Use e-mail to solicit experiences of colleagues. During the IHI project, e-mail was used in an unprecedented way, says Espinosa. "When an ED hits a brick wall and finds itself in a political challenge, which reason and logic suggest ought to be overcome, they now have the support of printing off the reasoned responses of dozens of their peers, many of whom did not have that problem with their administrators," he explains.
ED managers responded via e-mail to colleagues in the collaborative, providing leverage with reluctant administrators at other facilities. "When someone reaches out in our listserv, they may find that half the collaborative responds that they don't have that problem with their senior leaders, who are committed to change," Espinosa notes. "Their vote seems to have tremendous weight in the hospitals. When the directors are telling another director to go for it, they tend to listen."
Don't get discouraged if results aren't immediate. When Advocate Health Care took steps to reduce delays in its eight hospitals, numbers didn't change immediately. "You don't see an immediate change in the data, When you plot the next data point and it doesn't go down, it can be discouraging," says Micek.
The collaborative encouraged quick changes to be made. "IHI promotes a rapid cycle change rather than a long drawn out CQI process, with major changes over a month or two," says Bruce McNulty, MD, medical director of the ED at Ravenswood Hospital in Chicago. "The idea is to try it, modify it a little bit, and then implement it."
The EDs had to get used to making rapid changes. "For an organization not used to short cycle times, it has been difficult at times to stay committed over a course of months and maintain the momentum," says Micek.
To keep the momentum, patient satisfaction was used as the key outcome measure, with scores circulated monthly instead of quarterly. "Each of our EDs used the same tool to measure satisfaction, and we used a composite quality score generated from that," says Micek. "As scores improved, that was tracked along with decreases in delays."
Question everything you do. When Nash General's ED increased 21% in volume, delays needed to be reduced significantly. "The only other ED in the area closed, and we found ourselves overcrowded, overworked, and slowing down," says Clark. "It was also a huge PR headache because we bought the other hospital and decided it wasn't cost effective to keep it open. So if there were delays patients would say, 'Well, what did you close it for if couldn't handle patients here?'"
No single step was going to solve the problem, says Clark. "We started questioning everything we'd ever done and revolutionized our ED," says Clark. "We broke everything down to its smallest component." As a result of widespread changes, throughput times decreased from three hours to one hour and 40 minutes, he reports.
Ask staff for ideas. "We interviewed everyone involved in the care of patients, including nursing, radiology, and respiratory, and developed a master list of problems. We ended up with 40 items. Then, our process improvement team met every two weeks and worked through the list," says Jensen. "We tried the suggestions brought to us by staff, and if results were positive we immediately implemented the change, which empowered the staff to make policy."
Don't stop tracking delays after your goal is reached. At Nash General, an ED report card keeps track of every new initiative, and is updated monthly. (See Emergency Care Center Monthly Scorecard on page 113.) "The key is to never stop trending data. Otherwise you lose your gain," says Clark. "With that scorecard, everybody knows exactly where we are."
Show staff results. "You need to go for the quick wins early," Clark recommends. "When we switched to bedside registration, everybody saw the immediate impact, even though it was months before we saw a true decrease in our LOS," he says. "Those early successes showed staff that we don't have to keep doing things as we've done them before."
Cross train staff. Nash General's ED cut door-to-drug time for thrombolytics in half by cross training staff to do EKGs. (See Door-to-Drug chart on page 116.) "We were way outside what was acceptable, with a 60 minutes door-to-drug time," Clark recalls. "We cut that down to 31 minutes by cross training phlebotomists, so whoever is available does the EKG."
Use data to demonstrate improved patient care. Nash General's data showed improved treatment of pneumonia patients. "We were only treating 46% of our pneumonia patients before they went to bed upstairs. Since our census is high, they were waiting up to eight hours to get antibiotics," says Clark. The wait for antibiotics is now less than two hours, and 96% of patients are treated before they go upstairs.
It was also determined that patients were averaging one hour from arrival to chest x-ray. "That is the end of data stream for pneumonia diagnosis, and early treatment decreases morbidity and mortality," says Jensen. "It's not quite the urgency of time for thrombolytics to MI, but it is a significant issue."
Ten to 30 minutes was saved by notifying the physician immediately after the x-ray was completed, says Jensen. "The tech is the first person who knows the x-ray is done, so they do the work of closing the loop by flagging the chart so the physician is immediately aware."
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