Emergency Department Efficiency-Pearls of Wisdom

ED Efficiency-Pearls of wisdom

The list below represents a partial list of what operationally efficient emergency departments can accomplish:

Main Outcomes:

Timely patient service:
a. Increases patient satisfaction
b. Improves perception of quality of care
c. Eliminates patients leaving without being seen

High operational efficiency:
a. Enables control of patient flow
d. Prevents ambulance diversions
e. Prevents ED overcrowding

Marketability and recognition:
a. Increases peer standing
b. Increases community standing
c. Influences physician referral patterns

Controlled work environment:
a. Increases staff satisfaction
b. Improves staff retention rates
c. Facilitates recruitment efforts

Increased Hospital revenues:
a. Recoups losses from LWOBS and diversion
d. Shifts Market Share far from usual catchment
e. 10X ROI within 24 months from deployment

Lower hospital/staff liabilities:
a. No waiting room mishaps
b. Less LWOBS and AMA
c. Less errors of omission/medication errors

Main visible outputs:
1. No patients in waiting room
2. No patients in ED hallways
3. No ambulance diversions

Main patient flow metrics:
1. Door to Provider times of 22 minutes or less
2. Door to Release times < than 180 minutes
3. Door to Admit times of 3.5 hours or less


Core Strategic Objective:
“To prevent incremental patient backlogs from forming through peak times or significant volume spikes”.

First marker of successful deployment:
The ability to immediately bed most/all ambulances upon arrival.

The core strategic objective...a solution to all ED problems?
The root cause of emergency department breakdowns is the decrease in patient flow that results from incremental patient backlogs that form during peak times. Finding a way to prevent them represents the only true global solution to all major ED problems and allows all the outcomes above to materialize automatically.

But...isn’t hospital bed capacity and bed boarders the true cause of ED problems?
In traditional emergency departments patient flow is severely influenced by hospital bed capacity. That is why JCAHO and emergency specialty societies have made this the most visible culprit of ED overcrowding, diversions and lengthy waiting times. As a result, many improvement initiatives are now based on getting admitted patients to the floor faster and preventing boarding in the ED. Unfortunately this only benefits ED patient flow marginally and entails costly propositions like observation units, rapid admit units, more telemetry beds and canceling of elective surgeries and admissions. Needless to say, most hospitals have trouble with this.

In comparison, patient flow in operationally efficient departments is not held hostage to hospital bed capacity issues. In fact, they develop systems built to work precisely around the fact that hospital capacity problems will not markedly improve soon. They also operate under the assumption that ED expansion is to be avoided for the sake of operational efficiency. In essence, their emphasis is on creating new synergies, processes and support systems the ED itself can influence instead of concentrating mostly on the hospital bed capacity woes.

What about using “Six-Sigma”, ISO and other TQM methods?
Because of the complexities in trying to improve ED patient flow, many institutions have turned to Six-Sigma, ISO, and other TQM systems. Nevertheless, these methods are unnecessary to establish operationally efficient emergency departments. In fact, event though major consulting firms have applied Six-Sigma to emergency departments for several years most of the results are unimpressive from a truly operational efficient standpoint.

The truth is that “30-Minute” emergency departments develop their operational capabilities through the creation of an entirely new system format rather than through the reengineering of previously flawed processes.

In addition, by the time an institution finishes training “black-belts”, performs preliminary cycle process analysis, communicates results, and executes process reengineering several operationally efficient EDs could be implemented with time to spare. The problem with TQM methodologies is not only that they are time consuming but also that, after significant time and effort, departments just end “better” but not “World-Class”.

So then...what is the logical way to achieve the core strategic objective?
To concentrate on preventing treatment and disposition delays on the 80% of patients most departments treat and discharge everyday. Since admitted patients represent only about 20% of the daily patient load the patients discharged everyday actually determines how efficient an emergency department is at utilizing available assets.
This entails creating a new system in which non-admitted patients turnover within an average of 150 minutes from arrival through the door. (Door to Release times). Otherwise, the hospital bed capacity and output problems can start to have a noticeable negative effect on overall emergency department patient flow.

Which brings us to...Patient flow redirection.
Most emergency departments have underutilized treatment areas and resources that could be reassigned or reallocated to increase overall functional capacity and reach the Door to Release times required. In essence, most departments separate patients artificially or geographically (i.e. through graded triage, Fast-Tracks, pods, etc.) and this causes an inherent mismatch between resources, staff productivity and treatment space utilization.

For example, Fast Tracks typically address only about 20% of daily patient flow as they can only see minor complaints for which significant work-up is not expected. Since another 20% of patients are sick enough to require immediate treatment that leaves 60% of the daily patient load in the waiting room. These patients are in queue for main beds, which puts them in competition with ambulance patients and prevent their immediate bedding.

In contrast, operationally efficient departments reallocate resources to redirect all non-critical patients into these, and other underutilized areas, without restrictions. This markedly increases treatment space turnover by allowing early clinical decision making in the majority of patients. It also reduces dramatically the amount of patients in queue for main beds, which prevents diversion and allows immediate bedding of most ambulances.

Conceptually, patient flow redirection is akin to increasing the number of lanes in a highway to accommodate more of the traffic load entering that highway. Nevertheless, by itself, patient flow redirection does not increase the speed of those patients, as that is actually determined by the Intake methodology being used. In addition, having extra lanes does not imply all bottlenecks can be prevented if slow moving patients occupy most of them. This means that to realize full potential, flow redirection must be coupled with processes that increase the speed in which patients are processed to be seen and decrease the time waiting for tests and dispositions.

How does Provider Intake fits in all of this?
Because prolonged waiting times lead to poor outcomes, many attempt to accelerate patient intake by instituting provider-based intake ("Provider Triage"). Nevertheless, lengthy waiting times are just a by-product of the department’s inability to prevent incremental backlogs. Trying to address waiting times through faster intake, without addressing backlogs first, is like “putting the horse behind the carriage”. In fact, for provider intake to be successful, the amount of flow redirection that must be attained first is close to 50% of daily patient flow. Otherwise it is a liability.

To clarify, think about provider intake as promoting drivers to go at 100 mph in the highway. As long as the highway is clear of delays, or has open lanes, provider intake is a wonderful thing. But if not, those fast moving patients can actually crash into bottlenecks and compound them very quickly. That is why the patient flow redirection requirements of provider intake are so high. Many open lanes are required to prevent that problem.

For comparison, in set-ups that use rapid nurse screening for intake the amount of flow redirection required to prevent backlogs might be as little as 30%. Now, don’t get me wrong; under right circumstances, provider intake is amazing and should always be pursued. Nevertheless, to support it, all the elements necessary to prevent backlogs from forming must be executed flawlessly on a daily basis. Provider intake is just too unforgiving of any breakdowns downstream.

…If you need more proof.
We received a call in the past from a patient flow simulation software company requesting our perspective on patient flow. Their simulations show that, whenever they plot “team triage” scenarios, any benefit in flow is short-lived and goes away at peak census hours. Again, without the ability to prevent patient backlogs no department can provide consistent timely service during peak times regardless of how fast they can initiate clinical encounters.

What about using Chest Pain Units, Observation Units or “Multipods”?
Using ED resources to staff Chest Pain Units or Observation areas affect operational efficiency adversely whether those patients are kept in the ED proper or in a separate designated space. Remember the 80/20 rules. These patients are part of that 20% of the daily patient load that contribute little to asset turnover. Therefore preventing delays in the 80% of patients the department releases every day is more essential. Reallocating resources to these areas means fewer resources will be available to carry the ED patient flow redirection plans.

Think also about the multipod departments. Multipods took patient segregation to the extreme and did not live up to expectations. Whenever you segregate patients or resources in an ED you are creating areas that at times will be underutilized (thus not contributing to flow redirection) and at others will be overwhelmed (thus promoting backlogs). This happens because you cannot schedule patients to present to the ED like you can schedule elective surgeries. That means at any given moment, you cannot predict the population that will show up and adjust resources accordingly in real time. From an operational standpoint, that’s a logistic nightmare.

Therefore, a tenet in operationally efficient EDs is to never segregate patient populations or resources beyond what the Intake system requires. That means no Fast Tracks, Chest Pain Units, ED observation areas etc. Unfortunately, institutions look forward to establish some of these areas, staffed with ED resources, as a cost-effective way to increase inpatient capacity. Because of this, it may be difficult for them to grasp the effect this could have on their department’s ability to redirect patient flow, avoid diversions and ultimately drive inpatient admissions.

Now to...the organizational commitment.
It should be clear that an organization should not make any compromises that could derail the core strategic objective from being achieved as this could mean the difference between just being “better” vs. being an entirely new enterprise with a remarkable and marketable service format. The good news is that investing in operational efficiency is an outright bargain as it can usually be done within the current departmental infrastructure and with minimal capital investment. In comparison, most institutions will routinely waste millions in emergency department expansions, healthcare consultants and TQM implementations over time.

Which then brings us to…the Return On Investment.
Institutions must understand they already loose significant revenue to operational inefficiency. On average, every hour on diversion costs an institution $12,000 dollars and every LWOBS around $300. Nevertheless it goes deeper. There is a potential pool of customers that represent about 20% above current volumes that are not being serviced due to the fact that they get their care elsewhere. These are patients steered towards competing institutions either by choice of their primary care physician, the choices that the EMS community makes about where to take unassigned patients or just closer geographic proximity to competing hospitals.

To bring that 20% in and stop losses to EMS diversion and LWOBS something radical has to happen to the ED services. In fact, institutions able to do so reap unprecedented revenue increases within months. Think about Oakwood Healthcare System in Michigan, which got a $20 million increase in revenues year one on their pilot and from $50 to 80 million more of sustained revenues when the initiative was deployed through their network. Think about Landmark Medical Center in Rhode Island where the institution went from 12 million in the red to being on the black within 18 months of deployment. Think also about Pioneers Medical Center in Arizona where ED volumes increased 25% on year one while hospital collections went up 63% (more insured).

In fact, gaining operational efficiency essentially guarantees an increase in revenues due to the fact that the definition of a profitable enterprise involves the ability to utilize current assets at a higher rate while leveraging labor productivity. Although every institution has different needs to reach the core strategic objective, the investment is negligible compared to the return. Most will be able to do it for between half a million and 1.5 million dollars. For that, they get an emergency department able to obtain all the tangible and intangible outcomes described previously along with a potential return on investment of 10 times within a year or two.

In addition…the true Target Market is not the patient.
There are two major customers to which this kind of initiative is truly targeted. The first and most immediate one is the EMS community that would be able to immediately bed their patients without delay and not be diverted to other facilities. That can essentially happen as soon as the initiative is deployed and will immediately increase inpatient volumes and revenues without any advertisement. The other are private physician practices that would be pressured by their own patients to send them to the ED that has positioned itself as providing a service without equal. Since their choice of affiliation and the service provided by it reflects on their judgment, there is a powerful incentive for physicians to refer patients to the institution that provides them timely service.

The ability these departments have to shift market share is therefore dependent on shrewd positioning of their services in the minds of the EMS community and private referring physicians. Marketing to patients is a means to an end. If private physicians feel compelled to shift alliances due to a service their patients feel they cannot get elsewhere, a potential captive pool of several thousand patients will be captured. By the same token that means that service consistency is essential. The point of all this is that knowing the target of the initiative raises the stakes significantly. Private Physician Practices and EMS personnel are mass influencers with low tolerance levels. Therefore the organization must ensure the initiative has all the support required to deliver its promise.

In Summary
The discussion above was based on addressing some of the most common cognitive hurdles that implementers encounter when attempting to devise the right ED initiative and strategy. Namely, we have listed all the outcomes the organization can achieve, the core strategic objective that allow those to happen, the logical way to reach that objective, and the financial benefit of reaching those outcomes.