Culture change improves ED throughput
CMs work 24-7, space redesigned
When Bronson Methodist Hospital in Kalamazoo, MI, examined throughput in the emergency department, it determined that a culture change was needed to shorten wait time and make sure patients meet inpatient criteria and are admitted in the right status.
Among the changes implemented were redesigning the emergency department, developing teams of providers responsible for a particular set of beds and specific kinds of patients, and adding case managers who cover the emergency department 24-7 and are dedicated to working with physicians on patient status.
Today, the typical time for patients to be triaged into a bed is three to four minutes, and most patients see a provider within 20 minutes. Only 0.7% of patients leave without being seen.
“When we started this project, our first priority was moving patients through the system in a timely, efficient, and safe manner. This involves far more than just the emergency department staff because multiple areas affect patient throughput. We needed help from everyone in the hospital to achieve our goals,” says Patti Burchett, CHAM, director of patient access for the 405-bed not-for-profit hospital.
The hospital used the Lean concept to develop 10 to 15 projects to improve patient throughput based on input from the front-line staff in the emergency department.
“Making change is not about doing one big project and getting huge benefits. It’s all about developing a series of small projects and having everyone in the hospital look at opportunities to make things work better,” Burchett says.
The emergency department has 52 beds and experiences about 96,000 emergency department visits a year in an emergency department designed for 65,000 visits.
“The goal was to improve patient throughput in the emergency department and to improve patient safety. If you do the right thing for the patient first, everything else will follow,” says Carrie Kotecki, BSN, RN, director of nursing and emergency services.
When the hospital opened a new emergency department, the original plan was for all work to flow out of one central station. “The department was huge and this was inefficient and confusing. Our team looked at using the space in a way that we could more efficiently treat the patients,” she says.
The result was to develop four teams, each with a physician, a unit clerk, and a nursing component. The teams include a critical care team, a chest pain team, a fast-track area team, and a medical-surgical team. Each team is responsible for 10-15 beds that are in a specific geographic location. The hospital’s fast-track area helps take care of patients with non-emergent needs, leaving the rest of the staff to take care of patients with true emergencies.
“This has improved the turn-around time and increased efficiency because everyone is working in a smaller module,” Burchett says.
All patients who come into the emergency department are met by a greeter, a triage nurse, and a member of the registration staff. The nurse determines the patients’ chief complaints and triages them into one of four different triage bays. In the individual triage bays, another triage nurse gets more information and puts patients directly into beds in the emergency department as long as beds are available.
To help make sure patients are assigned to the right level of care, the hospital created a case management position dedicated to working with physicians on medical necessity and level of care. The position is staffed 24 hours a day, seven days a week. “These case managers interact with the physicians and facilitate the admissions process. We also have a social worker and another case manager in the emergency department who facilitate discharge plans for patients who are going home and handle transfers to another level of care for appropriate patients,” Kotecki says.
It took a while for the case managers to develop a good relationship with the emergency department physicians, Kotecki says, but now the physicians recognize that the case managers are there to make their life a lot easier, she adds. The emergency department case managers review about 60% of admissions.
“The hospital was losing money because patients were being admitted who didn’t meet inpatient criteria or who were in observation when they should have been admitted. We know that physicians want to take care of patients, not worry about regulatory requirements. The case managers understand InterQual criteria and can assist the physicians in making decisions,” Kotecki adds.
Like many hospitals, Bronson is inundated with uninsured and under-insured patients who use the emergency department for primary care. “Our primary care physician offices are very full. We have a large federally qualified health center that cares for many uninsured patients, but they can’t keep up with all the patients who need their services,” Burchett says.
The hospital has a close relationship with the community health center and is working with the staff to train them on how to use the LEAN techniques to implement process improvement initiatives. “We are giving them the tools they need so they can become more efficient and effective in achieving their goal of being a patient-centered medical home for large number of patients. Together, we hope to serve our patients in the most convenient and the least intensive environment for care,” she says.
At Bronson Methodist Hospital, the team tested the new processes for three months before asking the administration for additional staff. To justify the new case management positions, they tracked the denials of care for patients coming through the emergency department to show how much money was lost because patients were admitted in an incorrect status and compared that to the cost of the additional case managers.
It’s not enough just to analyze a situation and determine what to do to improve it, Burchett points out. “Equally important is changing the culture to make it happen. When improvements are determined by a team, that team should be allowed to implement their recommendations. Otherwise, you’ll lose all credibility and the ability to move forward,” she says.
Source
- Patti Burchett, CHAM, director of patient access, Bronson Methodist Hospital, Kalamazoo, MI. email: [email protected].
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