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Description of the Original Collaborative

Many cities are reporting dramatic increases in emergency department (ED) wait times and ambulance diversions, with serious implications for the health and health care of millions of people in the United States. ED utilization rates are rapidly increasing and many hospitals are operating “at” or “over” capacity. The crisis in America’s emergency departments has been considered the “canary in the coal mine” for health care, providing a warning that systemic problems exist and need to be fixed.

In response to this crisis, Urgent Matters, a national program funded by the Robert Wood Johnson Foundation, was created to identify innovations that would relieve emergency department crowding. Beginning with a collaborative of 10 hospitals, Urgent Matters provided a learning environment in which the selected hospitals could develop and test strategies and tools to reduce ED crowding and improve patient flow. The input/throughput/output model served as a conceptual framework for the activities of the original Urgent Matters hospital Learning Network.

Input factors control why people present to an ED; these include aging, morbidity, lack of alternatives and insurance status. Throughput focuses on the actual operations of the ED, including the design of its processes and the timely availability of medical specialists and ancillary services. Output factors affect the ability to move the ED patient on to the next point of care.

Urgent Matters has evolved through two distinct phases: Phase I (September 2002-April 2004) was the hospital collaborative period, where 10 hospitals selected through a competitive process collected and reported on standardized performance measures for emergency department care.

Phase II (May 2004 to February 2008) built on the hospital collaborative experience with Urgent Matters becoming a nationwide clearinghouse dedicated to finding, developing and delivering “best practices” to improve patient flow and reduce ED crowding. In Phase II, the program has focused on highlighting these best practices through its educational activities including e-newsletters, Web seminars, regional conferences, collaboration with key stakeholders, presenting and publishing on the issue.

Urgent Matters is nationally recognized resource among ED personnel and continues to expand its expertise on sharing field-tested initiatives, ensuring access to proven tools, developing emergency department and inpatient strategies and partnering with industry leaders to create performance measures.

The Urgent Matters Experience

Phase I Program Framework

During Phase I, Urgent Matters served as the national program office (NPO) for the hospital Learning Network that began in May 2003. Ten hospitals worked together in a collaborative learning process with expert advisors from Urgent Matters. Each site received technical assistance to develop and implement best practices to relieve emergency department crowding.

These hospitals developed and implemented strategies designed to improve patient flow and to reduce ED crowding. The improvement process was facilitated by web-based learning, site visits, and joint meetings with all of the grantee hospitals to share results. Urgent Matters demonstrated that hospitals could dramatically improve patient flow and decompress their ED without, in most cases,  investing significant financial resources.

Four of the ten Urgent Matters hospitals were selected to receive an additional grant to develop, implement and evaluate a specific innovative program of their own design. The strategies focused on increasing ED throughput and/or output in a measurable and replicable fashion through creating a Care Management Unit, smoothing the elective surgery schedule, using RFID technology to track patients, and implementing early care at triage.

Additionally, the NPO examined the interdependence between emergency department use and the health care safety net in ten communities throughout the United States. The main goal of the safety net assessment project was to develop comprehensive evaluation of the safety nets in each of the ten communities that served as the focus of the study. The assessments provided information to the participating communities about the residents who are most likely to rely on safety net services. Ultimately, the assessments highlighted key issues affecting access to care for uninsured and underserved residents and identified opportunities for improvement. 

Phase II Program Framework

Since the completion of Phase I, Urgent Matters has shifted its focus to educational activities that seek out national strategies to improve patient flow and reduce emergency department crowding.  A review of current best practices indicates that overcrowding can in large part be addressed through better hospital capacity and patient flow management with a highly structured approach using mainly existing resources.

Urgent Matters has become a communication clearinghouse for strategies on patient flow and ED crowding. The program disseminates best practices found in hospitals nationwide through educational activities, such as the e-newsletters and Web seminars. Urgent Matters is a portal for innovative patient flow strategies, creating a central resource for hospital staff to discover field-tested initiatives that can be tailored to their organization.

Urgent Matters has collaborated with industry leaders to discuss and develop ED performance measures and share field-tested initiatives. Program staff also act in an advisory capacity for state hospital associations, to national organizations and the federal government.

Lessons Learned

Several critical success factors emerged during the Urgent Matters Phase I & II work. The Urgent Matters experience showed that hospital can dramatically improve patient flow and decompress their ED without investing significant financial resources, but it takes commitment and several important ingredients:

• Recognizing that ED crowding in a hospital-wide problem, not an ED problem. If ED crowding is not viewed and addressed as a hospital-wide issue, any efforts to make changes will either fail or have limited success.
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• Building multi-disciplinary, hospital-wide teams to oversee and implement change. While these teams must include representation from the ED, staff representing inpatient services and other support functions are also necessary. The ability to move patients in an efficient and timely manner relies upon the interactions of many different units throughout the hospital.
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• Determining the presence of a “champion.” In order for the effort to be successful, one individual in a well-respected position must serve in the role as champion- “selling” patient flow improvement to the medical staff and executive management. The champion must become an advocate for improving patient flow and easing ED crowding.
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• Guaranteeing management’s support. Reducing ED congestion and improving patient flow must be priorities at the highest level of the hospital. The CEO should be vocal in her or his support for these initiatives. If hospital leadership walks away from efforts to improve patient flow, the chances for success will drop dramatically.
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• Using formal improvement methods. Rapid Cycle Change (RCC) is an effective quality improvement method to improve patient flow. Using RCC, hospital staff can bypass political and financial hurdles by testing small changes. This approach allows them to build quickly on successful results, accelerate towards the improvement process and achieve organizational buy-in. Thus, RCC offers flexibility and allows hospitals to initiate change with minimal financial risk.
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• Making transparency an organizational value. Sharing outcomes and results with all involved staff builds ownership and accountability. Data are not useful unless everyone participating in the process has access to the same information. Transparency of information can be achieved through simple, low-cost initiatives: in-house newsletter articles, staff e-mails, charts showing results and presentations to the hospital administration and board.
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• Committing to rigorous metrics. Data collection is an absolute requirement. Hospital staff must not only identify key performance measures, but collect and report them on a consistent basis. Although data collection is a significant challenge for many hospitals that may not already have collection methods in place, such data will ultimately drive important decision-making and increase executive support.
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• Finding the right balance between collaboration and competition. Collaboration and healthy competition enhance performance improvement. Sharing results, such as run charts of the key performance indicators, between departments and with other institutions motivates internal staff and administration to perform at high levels in order to be recognized as leaders.