This article is the first of a four-part series of articles focusing on emergency department improvement. Subsequent articles will deal with “Which is the bigger problem, the front door or the back door?” “The ED performance scorecard” and “The multidisciplinary ED performance improvement team.”
Hospital emergency departments (EDs) account for about 10 percent of all ambulatory medical care in the United States. According to a new report released by the National Center for Health Statistics (NCHS), there were over 102 million visits to the EDs of non-Federal, short-stay hospitals in the United States between 1992 and 1999. Although hospital EDs vary in annual volume, size and services offered, they all have one common question; how can we provide quality emergency medical care to our patients in a safe, efficient and cost effective way?
The answer to that question is not always an easy one. The multi-faceted processes of the ED open so many possibilities of areas that need improvement. Some of these areas are noticeable by patients and visitors that visit EDs. Some are seen and recognized by the physicians and staff that work in the ED. And some areas of improvement are important to administrators as they struggle to meet industry and self imposed benchmarks for providing emergency care.
With a national focus on decreasing numbers of full service emergency departments and reducing over-crowding, it is very important that clinicians and administrators adequately evaluate the current state of operations of their ED.
How to recognize a broken EDTo fix something that is broken, you first have to understand what the real problems are. In the ED, the real problems are usually hidden beneath many layers of distractions. These distractions include common complaints such as: not enough space, not enough staff, knee-jerk reactions to patient complaints, lack of proper management or lack of sufficient data to recognize trends. Despite the many distractions that may be present, an organized systematic assessment can bring underlying issues to the forefront and give clinicians, directors and administrators a better understanding of the current state of ED operations.
Performing an ED operational assessment To perform a thorough emergency department assessment, you must start with an approach that recognizes the key drivers of ED efficiency, patient satisfaction and physician/staff satisfaction.
ED efficiency How efficient is our ED? Where can we improve wait times? Why are our average turn around times so long? All good questions to ask, all should be answered. To understand ED operations, we must break it into 3 major process pieces, Ingress, Dwelling and Egress. In other words, getting patients into the department, providing care while they are in the department and discharging or admitting them when care is complete. Each of these major processes has several sub processes that are important to analyze. Usually there is not just one broken process that when fixed will improve efficiency. Instead, incremental improvements in each sub-process will have a positive effect on overall efficiency. Process analysis should include: Direct observation of patient flow through each process segment, structured conversations with physicians and staff regarding actual and perceived impediments at each process step, patient surveys that include verbatim comments and improvement suggestions and last but not least, time studies to document process inefficiencies and identify process improvement opportunities based on internal and external goals and benchmarks.
Data collection and validation The ED process can be compared to something as simple as moving through a line at the amusement park or to something as complex as building a house. The key questions to ask about any process are how long does it take to get started, how long does it take to get through the critical portions of the process, and how long does it take to complete the process. The common link is “how long”. To measure how long, you must measure each sub-process. Once measured, a better understanding will develop of where the bottle necks are, where the subtle process inefficiencies lie and where the most opportunity for improvements are hidden. Some EDs have automated systems that will simplify the analysis, others rely on manual systems where staff members record times and manually tabulate results. In either case, a manual validation of process times should be conducted to ensure that improvements are aimed at the right sub-processes.
Patient satisfaction Rule number one is: “always listen to what patients tell you.” Rule number two is: “always follow rule number one.” Patients gather great insight into process while going through the process. Although their comments may not include performance improvement jargon, they are great observers of process inefficiencies, bottlenecks and flow issues. Having a well-designed patient satisfaction survey is of paramount importance to any effort to improve an ED. As clinicians, we often design processes that are clinician friendly rather then patient friendly. When we couple the patients perspective with process analysis, performance improvement efforts can be aimed at improving patient flow as well as improving patient satisfaction.
Physician, staff and administrator satisfaction If physicians, staff and administrators were asked, “How is our ED functioning?” their answers would be inherently different. Physicians may say, “The ED is slow because our labs and x-rays take forever to get us our reports.” Staff may say, “The ED is slow because the physicians dont see patients fast enough.” Administrators may say “The ED is slow because it takes forever to get patients to admitted beds.” All may be true statements, but to effectively make improvements, each perspective must be heard and understood. A well-designed satisfaction survey with opportunity for engagement and follow-up must be included in performance improvement efforts. Engagement of all stakeholders in the ED improvement process requires some effort. But surveys, brainstorming, priorities, engagement, follow-through and process monitoring are buzzwords that hold meaning for a successful ED improvement initiative.
Successful ED improvement initiatives start with a formal operational assessment that reveals broken sub-processes, validates critical performance data, and incorporates formal input from patients, administrators, staff, and physicians. After a formal assessment, improvement activities can be prioritized in the areas that will help us meet our common goal of providing quality emergency medical care to our patients in a safe, efficient and cost effective way.
