Day one of the Urgent Matters Policy Forum: Creating a Framework for Transparent and Accountable Emergency Departments in America was attended by representatives from Learning Network II hospitals, including senior administration, and Urgent Matters staff, including participants from the RWJF, AHRQ, and HRET.
Arthur Kellermann, M.D., M.P.H., F.A.C.E.P., Senior Principal Researcher, Paul O’Neill-Alcoa Chair in Policy Analysis, RAND Corporation, opened the meeting with a Keynote address entitled, Building Transparency and Accountability in America’s Emergency Departments. Kellermann’s speech highlighted the critical role that emergency departments play in the health of the nation and the invaluable community service that they provide
Watch Arthur Kellermann's Keynote Address: Building Transparency and Accountability in America's Emergency Departments (Scroll to page 2 of 2)
Good Samaritan Hospital Medical Center
Since starting work on the Urgent Matters Project, the Good Samaritan team has seen enormous success with their chosen change strategy of improving the time to treatment for ‘MidTrack’ patients. Recognizing the relatively high morbidity levels of non-urgent or mid acuity patients returning to the ED after leaving without being seen on a previous visit, the hospital chose to focus on a solution to this problem. The innovation is similar to Fast Track – where patients with select complaints within emergency severity index (ESI) level 3 triage category are evaluated by a dedicated team and the diagnostic work-up is begun immediately upon arrival. The strategy so far has been a successful left-without-being rates for these patients has decreased from 7% to 4%. The hospital hopes this project will have larger implications for future ED redesign at hospitals everywhere.
The benefit of the Urgent Matters LN II initiative to Good Samaritan lies not only in the specific improvement strategies and measures that the hospitals will produce, but also in the way participation in project like this changes the hospital culture.
Hahnemann University Hospital
As part of Urgent Matters, Hahnemann University Hospital has implemented several strategies that directly impact patient flow in the emergency department. Hahnemann adopted the 5-level ESI triage system in August of 2009, and has been working to ensure consistency and establish standards in the way patients are triaged. Using the ESI system, Hahnemann has been able to observe and track the increase of level 4 and 5 patients and closely monitor the status of level 3 patients- innovations that would not have been possible under the old triage system. Hahnemann has also implemented peer chart reviews to ensure compliance with the new triage policies. In addition, the Hahnemann team is working to develop a comprehensive fast track program and training curriculum about ESI triage for new staff in the Emergency Department. These strategies are working; over the last year left-without-being-seen rates for the entire ED have decreased from 15% to 5%.
ED improvement strategies and results have been discussed at the highest level and leaders are informed and involved in all aspects of the project. Sustainable changes can only be made if the organization’s senior leadership is visible and supportive. In order to ensure sustainability, Hahnemann created an Urgent Matters team that truly represented the organization. By establishing a multi-disciplinary team of health professionals that includes physicians, registered nurses, nurse practitioners, and emergency room technicians, the organization has been able to generate interest in the project across the ED, and cultivate champions and informal leaders.
St. Francis Hospital
The desire to shorten emergency department (ED) length of stay and improve patient satisfaction prompted the organization to become involved with Urgent Matters Learning Network II. St. Francis recognized the need to improve its intake patient intake process. Prior to the involvement in Urgent Matters, St. Francis ran a Six Sigma project in the ED that facilitated the creation of a process for quality improvement and generated interest among ED staff. With a foundation and infrastructure in place, the hospital assembled an Urgent Matters team with the desire to share and learn from other hospitals and build upon the successes of previous quality improvement projects at St. Francis.
As part of Urgent Matters, St. Francis has established a standardized triage process and educates and trains ED staff on new polices and procedures. The new polices were designed collaboratively by ED staff and tested using rapid cycle change processes. This collaborative approach led to the emergence of informal leaders and improved communication between the ED and other hospital departments.
Urgent Matters has facilitated interdepartmental and interdisciplinary collaboration. The hospital’s left-without-being-seen rates have been steadily decreasing - currently around 1.5%. This is down from last year’s rates of approximately 3.5%. In addition, length of stay in the ED has decreased 6% over the last year while the volume has increased 3.3%. The St. Francis team is addressing the sustainability of the Urgent Matters project by creating an ED Workgroup to continue monitoring and improving triage processes, and developing a training program.
Stony Brook University Medical Center
When Stony Brook University Medical Center made a commitment that their ED would never go on ambulance diversion they recognized that improved patient flow had to be an organizational priority. As part of the Urgent Matters project Stony Brook redesigned the patient consultation process in the ED. The Urgent Matter’s team began by asking some big picture questions (i.e., How many consultations are ordered each month? How long does it take for each consult to respond to the ED? How long should it take a consultant to complete the consult and make recommendations for disposition?). After examining the process the team found that there are approximately 725 orders for consultation in the ED per month and the process for obtaining and tracking consults orders was in need of reorganization. By collecting data and working across hospital departments, Stony Brook was able to design a consult process that improved communications and reduced the average length of stay for each patient consultation by approximately one hour.
For Stony Brook University Medical Center Urgent Matters Learning Network II represented an opportunity to work with the prestigious Robert Wood Johnson Foundation and George Washington University and to bring national attention to innovative solutions emergency department crowding and throughput problems.
Thomas Jefferson University
Thomas Jefferson team has been using Lean and Six-Sigma to address patient flow challenges and focus on improving their fast track process. By segmenting patients based on acuity and sending those patients triaged at an ESI Level-4 and Level-5 to the fast track, the hospital is able to treat and discharge these non-urgent patients more efficiently.
To date the team has developed a number tools and documents to improve the hospital’s fast track, including specialized training for staff, a re-design of the process flow. By collecting data and using rapid cycle change techniques, the Thomas Jefferson team has found that the fast track program performs at optimal level when staffed with a NP, RN, and ED tech. Over the last year the average fast track turn-around-time decreased from 183 minutes to 96 minutes.
As a result of Thomas Jefferson’s participation in the Urgent Matters project, there has been a greater awareness of diversion and crowding as a hospital wide issue-not just an ED problem. Improving the fast track started as a department-level project, but as a result of Urgent Matters, the importance this project and a commitment to improving patient flow in the ED has become an organization-wide goal.
Westmoreland Hospital
By examining their processes, the Westmoreland Regional team realized that there were deficit in their internal communications processes. Thus, the hospital decided to focus its strategy on improving communications between the ED and inpatient units to improve flow throughout the system. The hospital developed an ED/Inpatient Report Tool to monitor and expedite patient flow from the ED to inpatient units. Since the going live with this tool in May 2010, they have been quick to dive in – implementing and testing a number of diverse strategies for improving communications, raising awareness of ED crowding and throughput issues at all levels in the organization.
By examining their processes, the Westmoreland Regional team realized that there were deficit in their internal communications processes. Thus, the hospital decided to focus its strategy on improving communications between the ED and inpatient units to improve flow throughout the system. The hospital developed an ED/Inpatient Report Tool to monitor and expedite patient flow from the ED to inpatient units. Since the going live with this tool in May 2010, they have been quick to dive in – implementing and testing a number of diverse strategies for improving communications, raising awareness of ED crowding and throughput issues at all levels in the organization.
In addition to aiming for improvements in how they deliver care within the Westmoreland community, the team is focused on the bigger picture of what the Urgent Matters work means for developing measurable ED interventions. Since embarking on in the Urgent Matters project ED boarding times have been reduced from 130 minutes to 80 minutes.
