Improvements in ED Patient Flow & Satisfaction Using a Patient-Centred Approach

Joshua M. Kosowsky, MD, FACEP

Vice Chair and Clinical Director

Department of Emergency Medicine

Brigham & Women’s Hospital

Assistant Professor, Harvard Medical School

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A bit about Brigham and Women’s Hospital

• Founded in 1913 • Teaching affiliate of

Harvard Medical School • U.S. News and World

Report “Top 10” Hospital • 793 inpatient beds • Core service lines include

oncology, cardiovascular disease, orthopedics, neuroscience, and women’s health

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The Emergency Department at BWH

• Level I Trauma Center • 60,000 annual visits (adult) • 1 out of 3 patients

admitted or placed in observation

• 19,000 square feet (undersized by ~50%)

• Board certified, EM-trained attending physicians

• Highly acclaimed EM residency program

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Why Emergency Department flow matters

• Front-door to the hospital • Strategic imperative to improve access • ED cannot refuse or divert patients • We don’t have a “4-hour rule” in the U.S!

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Where was our ED in 2009?

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Length of stay > 5 hours

Waiting room time > 1 hour

Walk-out rate > 3%

Patient satisfaction < 20th percentile

Volume stagnant year-over-year

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Process improvement in the ED

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Can’t be done We’re not the problem

It’s too chaotic We’re too

busy! It won’t matter

anyway

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Surveying the landscape

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Emergency Department flow

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FRONT-END

arrival

registration

triage

bed placement

MIDDLE

diagnostic testing

consulting

procedures

decision-making

BACK-END

discharge

admitting

observation

boarding

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Common themes

Leadership support

Front-line staff

engagement

Goal alignment

Performance measurement

Accountability

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Redesign team

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Impact-effort matrix

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Effort

Imp

act

Eliminate ED boarding

Streamline the admitting process

Improve diagnostic turn-around times

Reduce door-to-doc time

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Check-in

ED front-end process map

• Non-value added steps

• Serial processing

• Redundancy

• Bottlenecks

Is this a “Lean” process?

Bed assignment

Registration

Patient arrival

Triage

Bed placement

WAIT

WAIT

WAIT

WAIT

WAIT

RN sees patient

MD sees patient

WAIT

WAIT

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Top 3 opportunities identified

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(1) Bedside registration (2) Eliminating triage

A. “Any patient, any bed” B. “Bed ahead” C. “Clinical greeter

(3) Accountable systems

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(1) Bedside registration

• Simple check-in function on front-end

• One less reason for triage! • Reprioritize patients for

full registration on the back-end

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(2) Eliminating (the need for) triage

• Why triage in the first place? A. Sort which patients

go where B. Prioritize how long

patients should wait C. Identify the true

emergencies

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A. “Any patient, any bed”

Traditional model

Urgent

Specialty areas

Fast track

Acute

New model

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Any patient

Any patient

Any patient

Any patient

• Hazards of “mis-triage” • Frequent mismatch of

patients and resources

• Requires resources and staff training

• Must still allow for exceptions

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B. “Bed ahead”

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If bed is available, why wait at all? • Assign patients by rotation

system

If bed is not available, make a bed available.

• Each area responsible for staying “a bed ahead” at all times

Have an exception process for extreme census

• Emphasis on getting back into rotation

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Putting our money where our mouth is …

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C. “Clinical greeter”

• Initially instituted as a transitional role (concession to nursing traditionalists)

• Impact on quality measures (e.g., “door-to-EKG”)

• Can also do “check-in” (parallel processing)

• Huge patient satisfier!

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Stan

dar

d

Pro

cess

Ex

cep

tio

n

Pro

cess

Patient arrival

New process map

Check in

Bed ahead?

Assign bed by by rotation

Q

Yes

No

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(3) Accountable systems

• Established RN and MD leadership in each area

• New Flow Manager role

• Rounds with RNs and MDs in each area

• Identifies bottlenecks, reallocates resources

• Reports directly to RN Director and MD Director

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Our own “4-hour rule”

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Performance by shift

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Performance by physician

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So what happened?

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Waiting time (door-to-doc)

The average wait time declined from 68 minutes in

FY10 to 23 minutes in FY12 (a decrease of 64%).

More than half of patients are now in a bed within 10

minutes of arrival.

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Walk-out rate

The average walk-out rate has fallen from over 3% in

FY10 to 1.5% in FY12 (a decrease of 50%).

Most months, our monthly walk-out rate is around 1%.

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Patient satisfaction

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Percentile Rank - LG PG – Rec’d Date

Satisfaction scores for discharged patients has been at

or above the 90th percentile for the past 5 quarters.

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Patient satisfaction

Steady improvement trend in satisfaction scores for

admitted patients as well!

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ED visit volume

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ED volume is up more than 2,500 visits per year since

redesign has been implemented.

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Voice of the patient

“ VERY MUCH IMPROVED!!! Can’t compliment enough! 5 STARS”

“Best experience I ever had at any hospital - Exceptional !!”

“What a transformation!”

(Patient comments, 2012)

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Challenges

• Gaining buy-in of large and diverse staff

• Staying the course

• Our doors never close while we implement change

• Big change inevitably means multiple bumps in the road

• Maintaining our academic mission

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The road ahead

• Continual measurement and refinement • Sustaining change • Focusing on communication, cultural advancement,

and staff satisfaction • Broadening the scope of process improvement beyond

the four walls of our ED

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Summary

• Start with something relatively straightforward (e.g., bedside registration)

• To bypass triage, must eliminate the NEED FOR triage

• Any patient, any bed • Bed ahead • Clinical greeter?

• Cement change with systems of accountability

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Acknowledgments

• Heidi Crim – RN Director, Dept of EM • Ron Walls – Chairman, Dept of EM • Nancy Hickey – Associate Chief Nurse, BWH • Julia Sinclair –VP Clinical Services, BWH • Joe Camillus – Admin Director, Dept of EM • Christine Imperato – Admin Director, Dept of EM • Kristen Kadera – Senior Consultant, CCE • John Rossi – Senior Consultant, CCE

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Questions?

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“Drs. Wen and Kosowsky have insightfully crafted a revelation about the workings of modern medicine….It must be read both because most of us sooner or later are bound to seek health care and because the authors provide an important viewpoint for the intensifying nationwide health care debate.”

Bernard Lown, MD, Professor Emeritus, Harvard School of Public Health, Nobel Peace Laureate 1985

Thank you!!