Emergency Room Efficiency

Testing new app for blogging

2010-04-07T19:02:00.001-04:00

I'm testing a new blogging app through my iPhone. I hope this will encourage me to keep up with the postings in the future.

-- Post From My iPhone

What can we learn about ED Capacity and Patient Flow from Funnels?

2009-11-22T23:05:00.002-05:00

This is part of the support material for the ER Overcrowding Solutions Presentation at the bottom of this Post...

As it has been shown time and time again, an Emergency Department that doubles its bed capacity never ends up seeing double the amount of patients before it requires another expansion. Why is that? The reason is simple. When a Hospital doubles ED physical capacity, it never doubles inpatient capacity nor doubles the number of radiologists, consultants, lab techs, analyzers, transporters, etc. As such, even a modest increase in ED volumes puts significant strain on all the ancillary departments we need to help us service demand and the inpatient units we need to unload admitted ED patients to. This markedly increases variability in system interfaces and increases the time patients actually spend idle in ED beds.

To illustrate this, close your eyes and imagine we are pouring sand into a three-dimensional funnel. As we pour sand on the top of the funnel some sand makes it to the bottom opening and exits the funnel but, if we pour sand more briskly, the funnel will eventually fill up as sand is being poured in faster than it can exit. The sand that spills over the top (because it does no longer fits in the funnel), represents patients accumulating in the ED waiting room and hallways.

Now, let’s imagine we obtain a much larger funnel but this funnel has an even smaller opening to let the sand out. We will now be able to pour more sand initially into the funnel entrance and pack more sand within the inside of the funnel. Nevertheless sand is getting out more slowly. As we pour more sand, each individual grain of sand has a far longer and congested distance to travel from the top to the bottom and is also competing with far more grains of sand to get through the bottom opening. When this funnel eventually spills, the mess will be far greater. That is what happens to Emergency Departments that just expand…

By contrast, eliminating variability is the equivalent of widening the bottom exit of the funnel. The more variability we eliminate, the wider we make that exit. Now, when we pour sand on the top, it travels much faster towards the bottom exit and the funnel is less likely to spill.

If we were able to eliminate all variability, the bottom opening would widen to the same diameter that the top opening making in effect an open cylinder. In such a perfect system, the same amount of sand being poured at the top would swiftly exit the bottom no matter how much is poured into it and could never be saturated even if the overall size of the cylinder was very small indeed.

Unfortunately, such a perfect non-variable system is unattainable when we talk about patient flow. All we can do is to strive to open the bottom of the funnel as much as possible by decreasing and eliminating as much variability in the system as we can. The take home message is that decreasing variability is by far, the most significant, cost-effective, logical and fastest thing we can do to increase ED efficiency, improve asset utilization and free-up functional capacity. Anything else…including ED expansion, is doomed to fail…

Acute ED Decompression Plans

2009-11-22T22:53:00.002-05:00

This is part of the support material for the ED Overcrowding Solutions Presentation at the bottom of this Post.

An important management element to consider whenever we attempt to improve ED operations is the implementation of acute ED decompression plans. This involves the design of pro-active strategies that are aimed to facilitate prompt movement of ED admitted patients and/or Holdovers to non-typical or underutilized areas of the Hospital which may be able to take care of these patients at the time. The purpose is to avoid ED overcrowding by promptly redistributing a limited number of patients across several areas of the Hospital without overwhelming any particular unit involved.

Even though operationally efficient Emergency Departments can manage and control the flow of about 80% of their daily patient load, they are still at the mercy of inpatient capacity for the other 20%. As such, even the best managed Emergency Departments can occasionally run into trouble if inpatient capacity is fully maxed out or floor processes are misaligned with the acute needs of the ED. That’s why these Acute ED Decompression Plans are necessary.

Now…just as the ED has underutilized areas than can be tapped to promote ED patient flow, all Hospitals tend to have untapped capacity that could be allocated to support the ED on an occasional basis at particular hours of the day. For example…a limited number of stable ED admitted patients waiting for telemetry beds might be able to be divided between the unused capacity of a PACU and a Cath Lab Recovery Unit during the early operational hours of these areas. A limited number of ED admitted patients waiting for a Med-Surg bed might be able to be divided between the unused capacity of an Endoscopy Recovery Unit, an Ambulatory Care Center, a Maternity unit, and even a Pediatric inpatient unit during particular times of the day...and so forth…

Regardless of which of those areas or services may or may not be available at your Hospital, you are always bound to find some similar staffed areas which can be used to acutely decompress ED admitted patients. The problem is not usually finding them but rather, creating a viable plan that can be executed “on-a-dime” whenever the need arises. I am going to now describe some of the general steps necessary to come up with such a plan…

1st…We need to identify the thresholds for activation. This is obviously going to depend on the size of your ED, the extent of the boarding problem you are experiencing and the capacity of your institution. For the sake of argument, let’s say you have a large ED and your thresholds for activation will be having more than 24 holdovers in the ED at any time and any location. Your team might also consider activating the plan, regardless of the number or holdovers, if all beds in the Main ED are occupied or expected to be soon all occupied based on the number of expected ambulances.

2nd…Your team needs to identify the specific Units or areas that could help decompress the ED including …the types of ED patients each of those individual areas can take care of…the hours during which each of these areas could safely receive those kinds of patients…the number of patients each individual Unit or area could potentially absorb and; the limits beyond which each unit or area should never go over.

3rd…Your team needs to declare who will be allowed to identify the need to activate the ED Decompression Plan and who they need to contact next. These Activators might include the ED Charge Nurse, the ED Nurse Manager, the ED Case Manager…etc. After these “activators” have been identified, your team needs to also identify the people that will facilitate and manage the execution of the plan. These facilitators might include your Inpatient Flow Coordinator or Bed Czar, the inpatient nurse managers, the Director of Inpatient Case Management…etc.

4th…Your team needs to solidify the procedures, protocols and managerial elements of the plan including all the anticipatory steps that must be undertaken every day to prepare the institution in case the plan might need to be activated. For example…your institution might have your Patient Flow Coordinator review the OR schedule, and the expected utilization of all the areas involved in the plan every morning and communicate to all the activators and facilitators which of these areas can be expected to have available capacity in case the ED meets the thresholds for plan activation. In addition, other housekeeping elements and requirements of the plan need to be spelled out. For instance…your team might require that before any ED patients can be moved to a decompression area a verbal “Hand-Off” of care between an ED Provider and the admitting MD still occurs; that a nurse to nurse report take place, that the patient arrives to the decompression area with at least basic admission orders documented, that only patients deemed clinically stable be sent to any of the acute decompression areas…etc…etc.

One of the things that should be evident is than an acute ED Decompression plan must be orderly and unhurried in its execution…not a “knee-jerk” reaction. That’s why it is called a decompression plan instead of a surge capacity plan. In fact, a properly implemented ED Decompression plan (pro-actively activated whenever threshold is met and deactivated after the ED goes back under threshold) can obviate the need for reactionary and resource consuming institutional surge capacity plans from having to be activated as often.

Most of the time…all an Emergency Department needs to regain control of patient flow is to be able to turnover just a few beds within a short period of time before the next bolus of demand presents for service. Institutional Surge Capacity Plans, which are mostly reactionary and move at glacial speed, cannot provide this ability. By the time the bed meeting is accomplished, the Surge Capacity Plan is approved to be activated, the institution receives communication that the Hospital is in surge mode; and some capacity is starting to be freed up…the ED is so far down into the weeds that all these reactionary institutional efforts are basically powerless in arresting ED overcrowding. In contrast, Acute ED Decompression strategies are designed to meet the needs of the ED in almost “real-time” and decrease the need for the institution to implement highly disruptive, resource intensive and even unpopular surge capacity plans and actions…

To illustrate this point, one of the things some of our clients find surprising when they first meet us is the fact that we don’t advocate sending admitted ED patients to the inpatient hallways unlike many consultants Emergency Medicine Societies currently suggest. These people base their recommendations on the typical model most Emergency Departments operate under, nevertheless…the asset utilization, turnover, efficiency and increased functional capacity that is achieved through operational transformation strategies provides a significant operational cushion against overcrowding and reduces the extent of decompression the ED might require to avoid patient flow issues. As such, whenever a hospital implements these strategies they find that the ED can still operate efficiently with a number of ED admitted patients and holdovers that would have crippled ED flow and cause significant overcrowding in the past.

In other words, the threshold whereby the ED can get into trouble becomes much higher than before and the number of ED admitted patients the inpatient side will need to absorb to prevent ED operational decay becomes much lower. Most find that the simple Acute ED Decompression strategies we just mentioned usually suffice and that the institution doesn’t need to go into surge capacity mode as often. In fact, we have been involved with institutions that prior to our arrival were either thinking or already placing ED admitted patients into their inpatient hallways yet; after changing their patient flow processes, they haven’t found much use for this.

Strategic ED Staffing Plans

2009-11-22T22:40:00.004-05:00

This is part of the support material for the ER Overcrowding Solutions Presentation at the bottom of this Post...

-Very few Emergency departments and ancillary support interfaces adjust their staffing patterns to have more resources or most efficient members working the days of the week the ED is expected to have more demand. In addition, all departments have what is known as “fatal staff combinations” that should never be allowed to form. For example…having your slowest ED Physicians, your most inexperienced midlevel providers, your less effective charge nurse, your most novice ED techs and the least efficient X-ray Techs all working together a Monday afternoon is hardly a sound strategic choice. Unfortunately, these fatal combinations are allowed to form often and repeatedly in most Emergency Departments.

One reason most Emergency Department Managers cite for not approaching their schedule strategically is because of a shortage of staff members or too much variability in staff skill sets and capabilities. Although these reasons are valid sometimes, in most instances they just represent a “cop-out” for having to actually deal with the backlash that will inevitably ensue when the staffing preferences of some staff members are changed or from having to explain to some staff members why they cannot work on certain days or in certain areas of the ED.

Another barrier is that it takes a lot of time and effort for an ED Manager to create a strategic schedule that takes into account the whole department rather than just a particular group of people. For example, having a true strategic schedule would require that the person in charge of the nursing and Tech schedule and the person involved in the Physician and midlevel provider schedule both coordinate their staffing efforts to prevent fatal staff combinations from happening. The larger the Emergency Department, the more difficult implementing a strategic schedule becomes.

Nevertheless, the fruits of this endeavor can be very beneficial to the ED system and even the ED staff due to smoother system workloads and functional operations. All efficient enterprises adjust their staffing to cover more effectively their busier or seasonal demand days and try to prevent inefficient employees or managers from being scheduled together as much as possible. This is just common-sense.

Another reason strategic scheduling is so rare in Emergency Departments is that, in the typical overcrowded ED, the inefficiencies of some staff members are less visible amidst the chaos and idle time these departments must endure. Nevertheless, as a Department revamps operations and becomes more efficient, the effect that these fatal combinations and ad-hoc staffing approach has on the system become immediately visible. As such, Emergency Departments working on an operationally efficient model can identify these issues more easily and address them conclusively to reach the full performance potential the new operational model is designed to achieve…

Now...this is what must be done step by step...

1. Identify the busiest days and shifts and the lowest demand days and shifts of the ED based on historical data.

2. Adjust the staffing ratios so that you take some resources from the slowest days and transfer them to the busier days in a budget neutral way.

3. Classify all staff members (doctors, midlevel providers, nurses, techs, nursing assistants, X-ray techs, phlebotomists…etc…) as either A, B, C, or D players in the system based on their historical performance and capabilities.

4. Eliminate the D players as soon as possible (they shouldn’t be working in the system any way).

5. Make the schedule by taking your busiest days first and loading them mostly with A and B player across the boards. Afterwards, fill the rest of the schedule by keeping an almost equal proportion of A, B, and C players except in those areas that require a higher level of efficiency. If, due to staffing constraints, you must have a higher proportion of C players scheduled, try to only do this on the historical slowest days and shifts.

As a rule of thumb, never put two C players together if it can be avoided for obvious reasons. Also try to not put A with C players together but rather combine As with Bs and Bs with Cs. The reason for this is as follows:
When you put an A player together with a C player the C player knows he can’t keep up no matter what he does and will not attempt to make any adjustments in their performance. Meanwhile, the A player will tend to adjust his or her performance down partly due in reaction to the C players lack of productivity…Even worse, when you frequently combine A players with C players you will soon demoralize the A players and reduce their performance even more.

Now…when you combine As and Bs the dynamic changes as B players tend to adjust their performance up to more closely mirror that of the A player. When you combine a B player with a C player the dynamic is also different as the C players don’t usually see the performance of the B player as being out of reach and will thus adjust performance to more closely mirror that of the B player.

What I just discussed is based on numerous business productivity studies and is also very evident in sports performance. We all probably have witnessed this dynamic in action with major sport upsets in which a more gifted athlete is beaten by someone considered to be inferior. The usual reason for these upsets is that the gifted athlete adjusted his performance down and this allowed the inferior athlete to be more competitive.

The Dark Side of Hospital Staff Empowerment

2009-02-01T19:32:00.005-05:00

Now... before someone starts crying out...

We are all for staff empowerment. In fact, it is intrinsically woven into everything we do and help our clients accomplish. So much so that three of our clients submitted the patient flow transformational initiatives we helped them implement as their Magnet Status accreditation projects. All of them already received that coveted certification.

Needless to say, a well executed staff empowerment initiative is critical to true Hospital transformational change and the key to sustainable long term results.

Having said that...

A poorly executed staff empowerment program can be extremely detrimental to staff culture and can set an organization behind for several years.

The purpose of this post is to illustrate the perils of an ill-conceived empowerment program and enumerate the elements necessary to be successful in this endeavor...

Saying your staff is empowered does not make it so...

I’ve never heard a senior Hospital executive say they do not wish their operational staff be empowered or that they do not currently encourage this throughout their organization.

Why is it then that so few hospitals have Magnet status and/or have staff that feel disenfranchised?

Simple...true staff empowerment requires a protean effort and support from senior management to be implemented. In fact, the main reason to empower the staff is to encourage innovation and rapid cycle changes at the grassroots operational staff levels of the organization. By definition, this involves eliminating a lot of the bureaucratic, political, conceptual, and budgetary constraints to change that traditional Hospital administrators feel comfortable within. It also involves creating all the necessary supervisory interfaces to prevent “rogue” actions by the staff without stiffling them into inaction or despondence.

All this is obviously easier said than done within the highly structured and hierarchical managerial framework of most hospitals. In fact, most hospitals have clearly defined vertical reporting mechanisms and well demarcated departmental silos which tend to shield “sacred cows” and detrimental processes from scrutiny. Meanwhile, most of the changes necessary for these empowered staff teams to enact true system transformation run horizontally across departmental boundary lines.

Bottom line...paying “lip service” to staff empowerment just won’t cut it unless all these issues are addressed in the empowerment strategy.

Full empowerment versus graduated empowerment...which is better?

Sometimes well-meaning senior Hospital Administrators attempt to empower their staff “cold-turkey” without any preliminary training or facilitation...one day they have little say in administrative matters and the next “puff”...they are supposed to change and manage their work environment and their cross- functional interdepartmental interfaces without a hitch.

This is as perfect a recipe for disaster and staff alienation as can be conceived.

First, a little known secret...most of the formerly disenfranchized operational staff couldn’t care less about being “empowered” and will actually fear what this means in many levels. From their perspective, this sudden “empowerment” looks and feels more like an abdication of managerial duties by administration and gives the impression that administration feels that their problems are so pervasive that they are basically saying...here...now you guys fix it...

In fact, rather than welcoming “empowerment”, most operational staff members will avoid it like the “plague”. To obtain their commitment they need to be reassured, and fully informed that they will be supported, mentored, supervised and protected by administration during this transition. They will also find comfort if they know there will be strict parameters and guidelines within which they will be expected to work and clear communication channels with administration whenever they reach an impasse or encounter an institutional barrier they cannot circumvent. Otherwise...don’t even try it.

New format for article posting (my KNOL)

2009-02-01T14:56:00.011-05:00

The previous posts on this blog were based on articles that I have written over the years about Emergency Room Efficiency and Hospital Change Management. Nevertheless, the blog format does not lend itself to present these full-length articles in an appropriate way.

I found a much more "article-friendly" format to convey the information of these articles (called a knol)that keeps the advantages that a blog has for immediate communication (i.e. getting notifications of new articles, collaborate on edits, post comments, sign on to feeds, etc...)

Check out all previous blog postings in this new article-friendly format at:

http://knol.google.com/k/emilio-belaval-md/-/hit3f4qmzgcl/0#knols

or just click on the knol Link located above my picture to your right...

From now on, I will only post in this blog more succinct information in a more conversational style (including my unfiltered thoughts on Hospital Operations, Emergency Room Transformation and Hospital Change Management).

Any future full-length articles will be posted in the knol above instead of the blog...Regardless, I always post a notification on the blog that a new article has been added to the knol for those of you who might prefer to subscribe only to the blog feeds.

I will try to keep it interesting for you...

Emergency Department Efficiency-Pearls of Wisdom

2009-01-29T14:36:00.005-05:00

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.

Common Myths and Misconceptions About Operationally Efficient ERs

2009-01-29T14:34:00.004-05:00

Efficient ED-Myths & Misconceptions

Misconception # 1

Operationally efficient EDs see patients faster.

Many confuse faster care with timely service when in fact, they are different. The pressure to work faster happens when departments develop patient backlogs and get overcrowded. In this setting, staff needs to rush patient care and dispositions to bring waiting patients and avoid getting farther behind.

In contrast, operationally efficient departments see patients as they present without major effort. This prevents patient backlogs and also creates an unhurried work environment. This is actually achieved through well-planned patient flow redirection, reallocation of resources and optimization of ancillary services response times rather than by making staff work faster or changing clinical practice patterns.

Misconception # 2

Operationally efficient EDs compromise quality of care.

Skeptics clamor high service efficiency is incompatible with quality patient care. Nevertheless, in all measurable quality benchmarks, "30-Minute" EDs outperform traditional departments. Because they control patient flow and prevent overcrowding, these departments easily meet time sensitive quality measures and minimize the errors of omission that occur in departments where staff is overstressed.

The ability to provide timely service also decreases several other liabilities. In fact, operationally efficient departments have almost no patients leaving without being seen and dispense with waiting room mishaps, both of which represent troublesome medico-legal risks for emergency departments.

Misconception # 3

These EDs have more efficient staff.

Some think that these departments must have exceptional staff to meet a 30-minute service goal in a consistent manner. The truth is that in all departments, whether operationally efficient or not, the staff will have varying levels of skills and competence. Therefore, operationally efficient departments must be systems driven. In other words, to achieve consistency, operational guidelines must drive the processes that allow control of patient flow, rather than any given person or combination thereof.

To illustrate, in most of our client implementations the staff working prior to conversion is almost the same staff working after. Since the only thing that changed was the way patient flow was processed it can only be concluded that institution of a system that allowed them to work to the full extent of their capabilities was the main reason for the improvement.

This has implications for independent groups under threat of takeover. Because of pressure on administrators to find solutions to ED problems, they are induced to turnover the contract to whoever promises higher quality and efficiency through "better" staffing. As explained above, it is not the staff that needs changing but rather the traditional system hindering their ability to perform.

Misconception # 4

"30-Minute" EDs mostly increase "walk-in" volumes.

Although these departments increase "walk-in" volumes due to the convenience of the service they provide, this is only a "by-product" of their efficiency and marketability. In fact, the most significant and immediate effect of these departments is their ability to immediately bed most ambulances and decrease ambulance diversions. This increases inpatient admissions even before marketing starts.

Not only is this due to the fact that the department stops loosing ambulance patients to diversion but is also driven by sudden realization by the EMS community that they can now unload their patients immediately and enjoy some of the “down-time” built-in between their runs. This is an important determinant of EMS satisfaction and a powerful incentive to favor bringing unassigned patients. Since about 41% of ambulances get admitted a department that prevents EMS diversion and attracts more ambulance volumes, can become the most important and effective driver of inpatient revenue.

Misconception # 5

"30-Minute" EDs are a marketing gimmick and a passing fad.

Since operationally efficient departments provide an exceptional and consistent service some of them advertise a time to service guarantee. This has drawn criticism by some members of the emergency medicine community that contend these guarantees are a gimmick to attract market share and might lead to over utilization and trivialization of emergency department services. The truth of the matter is that these departments have a service with strong market appeal and competitive advantage. From a business perspective, it would then be naïve for them not to exploit this “first-to-market” status to its full potential before other operationally efficient departments become more ubiquitous in their area.

Misconception # 6

Emergency Department market share cannot be shifted.

Think about the Department of Motor Vehicles (DMV). Similar to emergency departments, DMVs do not have a compelling or discernible service difference and as such, people go to them based on geographic convenience. In essence, they are all positioned in the mind of customers within the same category. Now imagine one decided to apply the principles of operational efficiency and advertise service within minutes of arrival. In the customer's mind, this particular DMV has decisively positioned itself as the place to go if they do not want to spend the day waiting. As a result, this department will have a surge in visits from communities beyond their typical geographic catchment area some of which will be firmly entrenched within the service areas of other DMVs. This extended area is limited only to the time a customer is willing to travel to enjoy the more convenient service.

This is similar to what happens when a traditional department converts into an operationally efficient model and changes the service paradigm. Their efficiency allows them to not only reclaim patients from surrounding Urgent Care Centers but also siphon patients from other ED waiting rooms whenever they get overcrowded and receive their ambulances whenever they go on diversion. In our experience, this effect is felt even if the competing institution is more than half an hour away.

Although other misconceptions probably exist, these are the most common we have encountered so far. At this time, fear and resistance to these new and competitive services is natural and expected amongst traditional departments. Nevertheless, as operationally efficient departments become more common and more people are exposed to them, the impetus for change will inevitably increase and the need for logical discussions like the one above will become more evident. We hope this post contributes to the overall rational understanding of how these departments truly operate.

Hospital Change Management

2009-01-29T14:32:00.005-05:00

The change management hurdle

Most hospitals approach operational improvement as something that should be tackled by the internal resources already in place in each departmental silo. They expect each department to address their problems and come up with solutions within their budget. This is right for daily operations and incremental improvements. Unfortunately, it is fatal for multidepartmental change. In fact, most hospitals do not possess the internal change management skill set and methodological understanding to accomplish major restructuring.

With that in mind…consider the DICE score.
The DICE score is a useful tool to address the most significant shortcomings in a change management strategy. This score was developed by the Boston Consulting Group as an objective assessment of an organization’s capabilities to tackle change and was validated in over 229 organizations. To read more about it, log on to the Harvard Business Review website at www.hbr.org or to www.bcg.com/DICE to use the available online tools.

The beauty of the DICE score is that it can objectively measure the probability of success of an initiative prior to implementation. DICE stands for the Duration of a project and the frequency in which milestones are reviewed, the Integrity and overall capabilities of the implementation team, the Commitment of the senior administrative branch (C1) and operational level employees (C2) and finally; the amount of Effort and workload increase expected to be perceived by all the people involved in the change. For each of those parameters a value, based on a predetermined scoring system, must be given and applied to the formula below:

D+(Ix2)+(C1x2)+C2+E

The score goes from 7 to 28 and the lower the number the better. In fact, those projects with a score from 7 to 13 have a high statistical probability of being implemented successfully while those with scores from 19 to 28 are almost guaranteed to fail. Those with scores from 14 to 18 need to be improved to have a better chance. The scoring values to be given to each variable are thoroughly explained in the resources mentioned above.

As a matter of perspective, this tool implies that a short departmental project led by a cohesive, highly skilled team; championed by senior management; and implemented in an area where the staff is receptive to change would have a score of 7 and be guaranteed to succeed. On the other side, a multidepartmental initiative without clearly defined milestones; led by an unskilled team; with lukewarm senior management support, and implemented in areas where the staff is resistant to change would have a score of 28 and be guaranteed to fail.

As an objective measure of the organization’s capability to implement change, the DICE score helps galvanize support by forcing administrators to face reality. In fact, most hospitals attempting to implement this change have scores over 23. Confronted with that, the discussion naturally progresses towards how to improve this.

On that note…we have the effort conundrum.
In reality, organizations attempting to implement a “30-Minute” ED can’t lower DICE scores to 7 because the professional ED staff will have particular views about how much effort they are willing to put forth for an imposed initiative. Whenever effort is perceived to be more than 10%, resistance rises and the score reflects it.
The above implies that, to lower the scores to an acceptable range, implementers have to concentrate inordinately on the other variables, namely the DIC aspects.

Having said that, there are ways to preempt and manipulate the perception of effort of the staff to lessen the damage that resistors would otherwise accomplish.
Which brings us to...physician and nursing buy-in.

Since the initial amount of perceived effort by the staff will be high, regardless of the benefits in patient flow and satisfaction, preempted “buy-in” from a majority of physicians and nurses is critical to prevent active or passive sabotage right after implementation. Unfortunately, their support is difficult to gain, as they tend to view organizational change as an imposition on their professional rights. Nevertheless, they do respond to open communication and may in fact, demand it.

Disclosing and explaining the following can facilitate this process:

1. What we are trying to achieve.
2. Why we are trying to achieve it.
3. The consequences of keeping the Status Quo.
4. How the changes will look and feel.
5. The things that will benefit them.
6. The things that will be needed from them.
7. What the organization will provide to ensure success.
8. The changes that will come next.
9. When they will hear more about it.

The message above must be repeated over and over again and implementers must prepare to have their message challenged on several occasions. As part of this open communication, a formal mechanism must be instituted to allow these professionals the chance to contribute ideas, challenge controversial decisions, and be able to exert some influence on the final outcomes. This process helps manage unrealistic staff expectations by ensuring that rational, unbiased and logical debate actually takes place. This also helps diminish false “rumors” and arm supporters with the right knowledge base to disarm resistors trying to capitalize on disinformation.

But…you must actually paint two pictures.
The most important part of the buy-in process above is describing how the new changes will look and feel in the most realistic and descriptive way possible. In essence, to paint a clear picture of how things will be without any “sugar-coating” or hyperbole. Otherwise the staff will feel they are being “sold” an inaccurate picture with a hidden agenda. In fact, two different scenarios must be conveyed. The first one involves the immediate post-implementation period and the second, the long-term picture after the changes have been fully internalized.

The first picture is uninviting. The staff must be told that they will need to adjust to an entirely new work dynamic and that many will feel uncomfortable initially. That some will want to “regress” to old ways. That unproductive members will no longer be able to hide amidst former inefficiencies and their displeasure will be vocal; and finally, that some disgruntled members might threaten to quit although, in the end, few actually do.

Concomitant to that first picture, the staff must also see how things will be once they surpass the learning curve of the new system. The staff must understand that after the “dust settles”, they will be working in a more controlled environment. They must be told the clear benefits this system will provide to their patients, how much it will facilitate care and how much having no patients in the waiting room will decrease their liabilities. Finally, they must be exposed to the fact that most of the staff currently working in backlog-free operationally efficient departments states universally that they would never like to revert to the old ways.

Although the first picture seems brutally honest, it needs to be to serve its purpose. This effectively makes the staff understand that the scope of change is significant and that they should not expect an entirely smooth transition. This also sends the message that change is hard and that the implementers acknowledge this. It also establishes that implementers have a clear idea of the expected difficulties and will try to minimize the impact.

This is a lesson learned the hard way. Invariably most implementers take the position that they must shield the staff from the “unpleasant” aspects of change. Nevertheless, doing that only makes them irate when their expectations of a “trouble-free” transition do not materialize as sold. In the end, honest communication and debate go a long way to establish the rationale of the change, diminish anxiety and prevent resistors from negatively influencing the staff whenever process “breakdowns” occur during the initial stages of change.

Another thing that helps them buy-in… fixing “broken windows”
Criminal psychology experiments have shown that seemingly trivial crimes like graffiti, broken windows, aggressive panhandling and public disorder can invite and create the environmental context for other major crimes to occur. When a broken window is not repaired others are subsequently broken and a sense of anarchy spreads sending a signal that no one is in charge and that there are no repercussions for negative actions.

Similarly, trivial deficiencies and oversights can invite inefficiency and defeatism amongst the ED staff. As an example, with one client we identified that seemingly inconsequential problems, like a noisy air intake in the waiting room, lack of a water cooler for patients, lack of security at the doors and other minor oversights were demoralizing the staff in charge of greeting patients thus lowering their efficiency and inclination for customer oriented behavior. To them, these were major issues no one cared about solving. Similarly, many of these easy to fix “broken windows” negatively influence the behavior of physicians, nurses, techs and virtually everyone that interacts with or within the emergency department on a daily basis. This fact actually represents a wealth of opportunity to help garnish support and momentum for the change initiative. In fact, there are two advantages:

First, when the staff sees these “broken windows” being fixed, a sense of being finally heard starts to develop. In addition, each problem fixed represents a very specific victory for a particular faction of the ED staff. When several “victories” accumulate, the staff starts to acknowledge the perception that the upcoming change initiative is exerting a positive effect on the organization. The end-result is that they start to fear it less.

Second, the sense of order accomplished by this philosophy can improve productivity before the new system changes are fully implemented. By removing these perceptual barriers to performance you allow more productive behavior to come through while taking away the particular excuses used to justify prior deficiencies.

Basically fixing “broken-windows” establishes early on the fact, that the change initiative has “teeth” and can deliver positive relevant results if allowed to take course. Nevertheless, fixing these perceptual problems by itself is not enough to support major change or modify behaviors substantially. It is just an adjunct that can facilitate the buy-in process and transition of the staff in conjunction with the other elements discussed before.

And…what about ED “culture” change?
Many ask-how can I change the culture of the staff to work efficiently and provide customer oriented service? The fact is that you cannot change the culture; the culture must change itself with time. Remember we are not dealing with skilled laborers on an assembly line. We are talking about highly trained professionals, most of which have years of experience practicing their craft. Asking them to change their work habits and patterns is almost as difficult as asking them to change their religious beliefs or political affiliations. It just doesn’t happen.

When you develop an operationally efficient emergency department you automatically provide the staff with the controlled work environment and support systems necessary to leverage their intrinsic performance. This context is a powerful change agent all by itself. Basically, when the staff adapts to process patient clusters rather than allow incremental backlogs, they eventually realize they can have more “downtime” if they strive to process a cluster efficiently before the next one presents. This realization becomes so powerful that the “peer pressure” to service patients in a timely manner even collates down to the most unproductive staff members.

Unfortunately, this is a mute point for traditional departments because the incremental backlogs they form during the day do not allow them to catch up with patient loads until the late night or early morning. In comparison, operationally efficient departments catch up many times a day and keep waiting rooms empty during peak hours. This ability to catch-up and have “down-time” provides the most powerful incentive to work efficiently in an ED. When the staff actively pursues this on a shift-by-shift basis, the culture has changed.

Now…how do you also get all stakeholders and other departments to buy-in?
Unfortunately, many changes necessary to accomplish the objectives are not under direct influence or control of the ED but of stakeholders with few incentives to cooperate. In fact, managing the interactions of all the stakeholders required for the change is the most difficult aspect of trying to implement this kind of initiative. Nevertheless, it can be done if stakeholders are made part of cross-functional teams accountable to deliver results within a strictly defined period of time. The following explains the steps of this management approach:

1. Form Heavyweight Teams. These “multidepartmental” units are formed temporarily for the purpose of developing the process changes necessary to achieve the necessary capabilities and operational efficiencies. They must have representation from both, administrative and operational factions and be broadly integrated. These teams must also be accountable and fully empowered to take all actions necessary to execute the strategy.

2. Place them in a Fishbowl. This ensures that all these stakeholders with differing agendas work together with a common mandate for operational efficiency. The “Fishbowl” is basically a meeting process specifically engineered to make any action or inaction immediately visible to the entire organization. This diminishes dissent and establishes an unrelenting pressure to deliver results within a strictly defined period of time. The “Fishbowl”, is very important to manage change strategically. Once in it, there should be no escape to scrutiny.

3. Follow a strict Project Management format. Even though the “Fishbowl” is a powerful agent of change, if the strategy is viewed as undoable, it will not be enough to save it. To ensure compliance with bold initiatives the change process itself must be broken down into non-threatening elements easy for each decision maker to act upon within a scheduled amount of time. Since far-reaching change will invariably be overwhelming when initially stated, this structured project management approach is necessary to avoid initial “shock” and resistance.

Although simple in principle, this is logistically difficult to accomplish in the hierarchical hospital environment. Because of strongly defined clinical and administrative departmental lines, establishing the format above requires significant amount of time, effort and facilitation. That also explains why the ED cannot be the owner of the initiative and why visible senior management support is so important to overcome organizational inertia.

But…we have a multidepartmental patient flow committee…what’s the difference?
Plenty. Although having a multidepartmental Patient Flow Task Force seems like the institution is going in the right direction, the reality is otherwise. The truth is that these “teams” do not usually have all the influencers, resources, budgetary leeway, and empowerment to establish changes in a rapid fashion. In addition, they are not placed in a strictly enforced project management schedule and their inactions are not immediately accountable to the organization. In short, these teams do not act like “Heavyweight” teams in a “Fishbowl” and are a liability because of a tendency to analyze, report and suggest rather than take decisive relevant actions.

Besides, most of these teams do not have the change management skills and experience to design or implement a “30-Minute” ED strategy. If they did, most departments would be operationally efficient by now. Although they have value when attempting to improve services incrementally, they are mostly powerless when the objective is to transform the department into an operationally efficient entity with an entirely new service format.

Should we conduct trials before fully committing?
No. For starters, “trials” mostly test the system in an artificial environment that does not accurately depict the synergies and interactions the system will ultimately require to be consistent. Second, trials carry a connotation of noncommittal and open the door for a vocal minority of resistors to influence the outcome. Therefore, to tip the scales in favor of change, the strategy has to be implemented in a committed, almost grandiose way, without any hesitation and under a strict timeline. In fact, the administrative support must be “in-your-face”.

In Summary:

If an organization decides to proceed without a change management strategy that accounts for all potential shortcomings, they run the risk of “spinning their wheels” for a long period of time. I know institutions that between performing “trials” and trying to put together all elements necessary to obtain synergy and support have wasted significant amounts of effort, time, and money to be nowhere near completion.

Furthermore, the first mistake is to make the emergency department primarily responsible to carry these changes. Due to the multidepartmental scope of these initiatives, the ED resources do not have the internal credibility and project management skills to establish change cohesively. Stakeholders tend to default to a departmental silo mentality and must be in fact, coerced to work cross-functionally and review milestones frequently. The emergency department is just not influential enough for this. The lesson of this is that becoming a “30-Minute” ED cannot be another departmental improvement initiative but rather an organization-wide strategic pursuit.

That is why implementers should use the DICE score to assess how well the hard-elements required for change have been addressed and the chances that their particular combination of factors will culminate in successful implementation. In fact, in organizations that cannot seem to understand the scope of commitment needed for this kind of change, presenting them with their DICE scores might be all that is needed to garnish support.

Following the change management strategies discussed in this post will help lower the DICE score into the right range and help implementers reach the critical tipping point for change in the most effective, timely and painless way possible. Otherwise…wheels might keep on spinning and spinning.

ER Efficiency-Principles and Pitfalls

2009-01-29T14:31:00.005-05:00

Devising the Operationally Efficient ED: Principles and Pitfalls

Principle 1: Insist on realism

Let's face it, if converting into an operationally efficient emergency department were easy, most departments would have found a way to do it already. The fact is that emergency departments have been under pressure for a while to find solutions but most organizations do not know where to start. Operational efficiency and productivity have not been part of the lexicon of emergency department management and many hospital administrators even avoid speaking in these "business-like" terms. Furthermore, since some believe emergency departments loose revenue on outpatients but drive inpatient admissions, many hospitals approach the ED as a "Loss Leader" (a service not intrinsically profitable but that provides exposure to profitable ones). Therefore, development of emergency department services is mostly reactionary to capacity and PR issues rather than strategically focused.

In addition, some hospitals have medical staff members that can quickly adapt to change while others have a staff that will be suspicious and clamor quality of care will suffer. Some members might also have interests in urgent care and ambulatory clinics in the area and will view an efficient and marketable emergency department as a threat to their own bottom line. Resistance will come from many angles and implementers must be realistic about the organization’s capability to execute change.

Principle 2: “Home Grow” your strategy

Operationally efficient EDs can be set-up in different ways and success is not dependent on any particular method but rather on the metrics that must be attained. Therefore, trying to copy a successful set-up from another institution can be counterproductive as each organization has divergent requirements and capabilities. Implementers must then have a good handle on their particular organizational idiosyncrasies and adapt the strategy accordingly. The following case study illustrates this point.

CASE STUDY: Strategy Design

Medical Center-University affiliated
80,000 yearly ED volumes pre-engagement/almost 100K currently

Because of population growth this large emergency department started to develop problems with overcrowding, lengthy waiting times and ambulance diversions. Therefore we were contacted to help establish an operationally efficient system based on a provider intake methodology. The client had vested their hopes in such a format and was truly interested in exploring that option. Nevertheless, during discovery we identified the department did not have the right capabilities and culture to support provider intake. First, physicians typically do not have the aptitude for the “intake” function so most successful provider intake set-ups utilize mid-level providers which are more comfortable in this setting. Although the department already used mid-levels, their scope of practice was limited and they were not allowed to work independently. This made the provider intake function impossible for them to perform. In addition, they had only a few full-time mid-level providers which meant several would have to be hired and those already in the staff would have to be re-trained.

Contrary to the mid-level situation, this department was well staffed with physicians and had a good pool of nurses. Because the department had a Fast-Track, there was also space available to redirect patient flow. Therefore, a decision was made to use an RN Rapid Screening format and utilize clinician resources more effectively. The Fast-Track was converted into a staging area and the former triage area was turned into several rapid screening spaces. After implementation, the department was able to redirect 53% of the daily patient load through these areas allowing the main pods to immediately bed most ambulances. Door to Provider time decreased by 67%.

This example illustrates the potential perils of attempting to devise or copy a strategy. Any other methodology than the one utilized would most likely have failed. Therefore, successful strategy design and execution is based on the ability to fit the major process and system changes within the current capabilities and culture of the organization. Furthermore, deciding between Intake methodologies is actually the easy part. The hard part is to identify the process changes required from all ancillary departments, stakeholders and the organization as a whole and being able to incorporate them in the overall design of the strategy.

As an update...this Department continued to work hard on developing the capabilities necessary to establish a viable Provider Intake system and improved Hospital interfaces. In fact, their metrics have continued to improve in spite of a significant volume increase...Their current Door to Provider time is only 19 minutes and over 40% of their entire daily patient volume load is discharged from the ED in under 120 minutes.(NOW...THAT'S EFFICIENT)

Principle 3: Have a change management strategy

In any organization there are influential and charismatic individuals that can either positively or negatively influence your initiative. They might be executives, middle managers or staff employees that seem to carry the pulse of the organization and can effectively influence the masses. These people should be identified and placed in a structured environment to work together with a common focus and mandate for operational efficiency. This environment must make any action or inaction immediately visible to the entire organization to diminish dissent and establish peer-pressure to act. In addition, the change process must be broken down into non-threatening elements easy for each decision maker to act upon within a scheduled amount of time. This project management approach is necessary to establish an environment conducive for stakeholder decision-making and compliance.

Principle 4: Address the masses

Even if you follow all principles in this article, everything will fail if your operational level staff feels in any way disenfranchised from the process. To prevent this, anyone affected by change must be allowed to participate in the restructuring process by creating mechanisms to allow discussions, exchange of ideas and interactions with decision-makers. The staff must be given the chance to provide suggestions, debate controversial decisions and to come up with their own solutions. After everyone has been engaged in the change process and the rationale of major decisions has been explained, all people involved must understand clearly what is expected of them in the new system. Therefore very detailed and specific operational guidelines must be developed for the staff to follow.

Principle 5: Think in “Operating Guidelines” terms

As alluded to above, deciding on a particular methodology is just the “backbone” against which all the other myriad of process changes will be developed around. Make no mistake; there will be hundreds of inefficient processes to identify, revamp and delete along with numerous better ones to develop. This can become unwieldy if a repository of information and instructions is not created along the way. Developing the operating guidelines for your system is therefore the most important principle to follow in order to successfully implement change. These guidelines will essentially be the “marching orders” for all to follow and become the main communication instrument for self-directed learning. All questions about the way patient flow is processed in the department, along with any surge protocols required to address particular situations, must be part of these guidelines. In addition, a formal protocol to add, change or delete any guideline must be developed and enforced to prevent resistors from using their own personal criteria to the detriment of the new system.

This is actually the main difference between operationally efficient and regular emergency departments. Although all have clinical protocols to follow, most emergency departments do not possess guidelines to define how patient flow will be processed and establish clear expectations for all the stakeholders involved in the process. This deficiency arises from the mistaken perception that clinical protocols and operating guidelines are equivalent when in fact, they have nothing to do with one another. The former is for clinicians and nurses to follow already established “best-practices” with a focus on evidence based medical practice. The latter addresses how patients are processed from point A to point B and has nothing to do with the way clinicians perform their clinical decisions or interact with their patients. In other words, operating guidelines do not dictate or suggest how clinicians practice medicine but rather define how the patients will get to the point that those clinical decisions can be made and how they will be supported along the way.

In fact, the ability to create proper operational guidelines cannot be understated. All successful business enterprises spend significant time and effort developing them without exception. From a business perspective, they are necessary to prevent degradation of performance and deliver a consistent service. The reality of the situation is that an emergency department without operating guidelines is in essence a dysfunctional multi-million dollar enterprise left without direction.

Principle 6: Consider an outside agent of change

Proper planning, project management, staff education and meticulous follow-up are required to implement an operationally efficient emergency care model. Conflict resolution between departments along with constant redirection of individuals falling behind schedule must also occur. Although the principles described in this post increase the chances for a strategy to be successfully devised and implemented, many organizations lack the right resources to develop and execute this kind of strategy from within. In addition, since hospitals tend to follow hierarchical reporting mechanisms and promote departmental silos resistant to change, minor opposition from medical staff members, other stakeholders or the ED staff itself can derail the resolve of the institution. In this situation a contractual agreement with a third-party might be needed to galvanize organizational commitment. Furthermore, where overcrowding is common, the staff might be conditioned to be suspicious and cynical about the resolve of the hospital administration to improve their working environment. Under these circumstances the staff might also transition more easily if they perceive that an objective third-party, rather than the hospital administration, is driving the change process.

Principle 7: Disrupt the Status Quo

With major initiatives, the chances of coalitions being formed against change are more likely if resistors have time to organize. Coalitions against change should be expected because operational deficiencies will be unveiled and discussed for the first time in the open and some might view this as an impugnation of their capabilities. Therefore, organizational restructuring must happen in a relatively swift way to prevent resistors from obtaining a significant support base. If change is only incremental and does not disrupt the status quo, resistors will invariably have the motives and the means to try creating instability in the transition process. To prevent this, the strategy for converting into an operationally efficient ED should be executed in six to nine months. This allows enough time to change the main processes appropriately while preventing resistors from influencing the outcome negatively.

Principle 8: Manage the “Neutral Zone”

After restructuring, there is a period where the staff is internalizing new processes and feels uncomfortable with the new system. There might even be a kind of nostalgic longing for the old ways due to the fact that the staff felt more competent then. During this time some of the staff might try to regress to old familiar processes and interactions and use their own criteria rather than follow the operating guidelines. This can jeopardize long-term success if mechanisms to diminish feelings of inadequacy are not accounted for. Information and constant clarification is therefore necessary to diminish anxiety. In addition, the staff will not immediately see the benefits the new system confers to them and their patients because they are still going through a learning curve. During this time, the fact they are able to provide timely service will look more like an imposition than a benefit.

Implementers must also be aware that other forces might also be at play. Even though the system will immediately leverage the majority of the staff to produce consistent and extraordinary results, operational efficiency promptly unmasks the shortcomings of the most unproductive staff. In other words, in a chaotic and overcrowded environment it is easy to hide deficiencies and some of the staff might actually depend on this. When the new system starts this “fail-safe” is eliminated and affected members will attempt to discredit the process in a last ditch effort to derail change. This is a fact of life for any enterprise that obtains operational efficiency and implementers must anticipate this.

Having said that, this is also the most prolific time period of the conversion. Until the new system goes live, most of it exist conceptually only on paper. As such, the majority of the “fine-tuning” required will happen during this pilot stage. In fact, a significant amount of what will eventually end up as part of the operating guidelines of the system will be developed over the next several months. This is to be expected as it would be naïve to assume that the implementers have been able to account for all the new interactions and process synergies required prior to seeing the system in action. Notwithstanding the fact that the new system should be in use within six to nine months from the start of the change initiative, in our experience, the entire conversion process will take about two years of constant revisions before reaching an operationally efficient “steady-state”.

This post represents an attempt to provide a realistic view of the scope of organizational restructuring required for establishing a “30-Minute” ED and the pitfalls to avoid. Our purpose is not to discourage potential implementers but to actually increase their chances for success by describing all the elements necessary for change from our experienced and objective viewpoint.

The Metrics of Operationally Efficient Emergency Rooms

2009-01-29T14:17:00.004-05:00

The Metrics of Operationally Efficient EDs

Operationally efficient EDs, by virtue of their focus on efficiency have different metrics and benchmarks than other emergency departments. In essence, many classic “Best-Practices” benchmarks do not even apply to these EDs. For example, the benchmark of less than 2% of patients leaving without being seen is meaningless as these departments usually keep those numbers below 0.5%. The truth of the matter is that these entities are in a league of their own and as such can only be benchmarked against each other. Nevertheless, the metrics pertaining to these departments have not been widely published. Through this post we draw on our personal experience implementing such departments in an attempt to define a standard. Furthermore, operationally efficient EDs can be set-up in different ways and in our experience; success is not so much dependent on the particular methodology used but rather on the metrics that must be attained to reach this capability.

In the discussion that follows we don’t intend to differentiate between departments that use Provider Intake vs. Nurse Rapid Screening or Immediate Bedding methodologies. Our purpose is to illustrate metrics shared by all “30-Minute” EDs rather than suggest a particular strategy. Discussion of the tactics used to obtain the ancillary turnaround times presented is also beyond the scope of this article.

1. Intake (Door to Provider)

The Intake category includes all the processes that happen from the time a patient enters through the door to the time the patient is actually seen by a provider of care. The consensus metric for an operationally efficient ED is an average Intake time of 22 minutes or less. This is the easiest metric to attain in the short-term as most intake processes are under direct influence and control of the ED. By the same token, it is also the most brittle metric as it fully depends on efficient Non-Admit Throughput times.

The rationale for the 22-minute cut-off is that when the ER is able to maintain this Intake time the vast majority of outliers tend to fall within the next 8 minutes. This is critical for departments that advertise a 30-Minute guarantee. By the same token, if many outliers fall out of the time to service goal, trying to decrease Intake below 22 minutes to compensate is futile. In fact, the only way to get the outliers in line with the performance goal is to achieve better Non-Admit Throughput times (Door to Release).

2. Non-Admit Throughput (Door to Release)

Throughput of non-admitted patients is by far the most important and dominant metric. In fact, without efficient non-admit throughput times it does not matter how efficient an emergency department is in Intake and Admit times, it will never be a “30-Minute” ED. This metric goes to the core of operational efficiency, as it is a measure of both, efficient bed turnover and staff productivity.

This is also the most difficult to influence, as some of the processes related to this metric are in hands of stakeholders that might not have a clear-cut incentive to attain the efficiency required to sustain the strategy. This metric actually represents a combination of factors that in average must provide for an overall non-admit throughput time of less than 180 minutes. Although a “bulk” of the improvement in this metric is achieved by the ED itself through a concept known as patient flow redirection (explained in a later post), we will now concentrate in the ancillary contributing factors:

a. Radiology turnaround times (Plain films)
b. Lab-work turnaround times (CBC, Chemistries, CK, MB, Troponin)
c. Transport turnaround times

As part of the implementation strategy the ability to obtain plain radiology turnaround times in the 25-minute range from order to completion is imperative. That means that your process reengineering must allow an X-ray response lag time of only 5 to 10 minutes to initiate the process. If the response time takes longer radiology backlogs will start to appear and the cut-off will not be met.

Some might be wondering why we do not include CT, Ultrasound, and MRI turnaround times and rather concentrate only on plain films. The answer is simple. These specialized tests have too much variability in the way they are performed, read, and prepped for. For example, a non-contrast Head CT must take no longer that 45 minutes from order to reported result but an abdominal CT with oral contrast might take 2 hours just to be performed. In the end, the actual amount of these tests performed in any given day pales in comparison to the amount of plain films an ED generates. Therefore, the ability to standardize plain film turnaround is more critical to overall efficiency.

Similarly, the ability to obtain a full cardiac work-up turnaround time in the 35-minute range from order to completion is desirable. That means that your process must allow a response lag time of only 4 minutes to initiate the blood draw process (order-to-vein) for the lab to be able to meet the mark. The rationale of using Cardiac work-up as the defining metric is that it represents a worse-case scenario. In fact, very seldom do we order just a CBC or just Chemistries or just Enzymes. Nevertheless, individual metrics for CBC, Lytes, Etc. can also be utilized although they might not be inclusive markers of efficiency. Individual times must be around 18 minutes for a CBC and around 28 minutes for simple chemistries. Better times can be obtained through Point-of Care testing but if these metrics are met by your current or future processes they are enough to sustain the strategy.

Some might also wonder why we do not include Urinalysis, pregnancy tests, and other commonly performed laboratory tests turnaround times and rather concentrate only on CBC, Lytes and Cardiac Enzymes. The answer is also simple. These tests have also too much variability in the way they are performed and obtained. For example, obtaining the urine for a Urinalysis or a pregnancy test can be a quick process (if the patient can urinate “on the spot”) or a prolonged process that might include hydration or bladder catheterization.

Furthermore, Point of Care testing for pregnancy tests can be used to improve the efficiency of resulting a particular sample, but it still does not obviate the need to obtain the urine first. Therefore Urinalysis and urine pregnancy tests do not lend themselves to benchmarking. Nevertheless, by concentrating on commonly performed tests like CBC and Lytes you do not only obtain a measurable metric but also provide “by-proxy” a rough guideline for staff to follow. In other words, if all lab tests are back in 35 minutes the staff tends to adapt itself so urine samples are obtained in a way that they can be resulted within that time.

Finally, institutions utilize transport in several different ways and capacities. If they are involved only in transporting patients to the floors then their response time does not affect Non-Admit Throughput times as much as Admit Throughput. Nevertheless, if they are involved in transporting patients to radiology and other specialized testing areas their response lag time cannot be more than 10 minutes from the time they are called to the time they are physically moving the patients.

3. Admit Throughputs

There has been emphasis given by JCAHO and EM Specialty Societies to prevent the practice of boarding admitted patients in the ED. They actually view this as the major determinant factor in ED overcrowding.

We do not contend that bed boarding is a negative and undesirable situation in any emergency department. Furthermore, we agree that, for traditional emergency departments, the statements made by those societies are right. In essence, the ability to see new patients and provide a disposition is severely curtailed whenever admit turnaround times lengthen and admitted patients are boarded. This situation can stop patient flow and produce incremental backlogs that can take hours to process. When sustained, the end-result of this breakdown is what is referred to as ED overcrowding. This further translates into a general sense of defeat and lack of control that paradoxically causes a decrease in staff productivity and efficiency at the time that is needed the most. Patients are also negatively influenced by this situation, as the “chaotic” appearance of an overcrowded emergency department undermines their confidence in the department’s ability to provide them proper care.

Having said that, operationally efficient departments behave and respond in ways that cannot be compared to traditional emergency departments. Because of the emphasis on efficient Intake and Non-Admit Throughput Times these departments have a significant “cushion” against this kind of operational breakdown. The most direct evidence is the fact that many operationally efficient EDs advertise their service. Logically, this could not happen if these departments where not able to handle previous patient loads in a more efficient way after conversion. Furthermore, after the advent of marketing, most “30-Minute” EDs have reported dramatic increases in patient volumes (25%-40%), without eroding the ability to meet the metrics above and maintain their 30-minute service advantage.

The most basic explanation for this is that only about 20% of ED patients are admitted while 80% are treated and released every day. This means that ED internal processes (along with ancillary department interfaces), are responsible for the turnover of the vast majority of ED patients. Operationally efficient EDs are able to process that 80% promptly and efficiently even while the Hospital is having problems moving the ED admits that constitute the other 20%.

By the same token, no system is perfect. Although a properly implemented “30-Minute” ED can handle increasing volumes and avoid overcrowding under most circumstances, you can only pack so much efficiency within a constrained number of treatment spaces and staff. Expectedly, a breaking point can eventually be reached if volumes continue to surge while the hospital’s ability to admit patients in an acceptable time frame lingers or deteriorates due to bed capacity or staffing issues. This needs to be anticipated and preempted to prevent a decline in service performance. For those reasons we suggest following the “Best-Practices” benchmark of 3.5 hours from door to admission.

Note: Although at the beginning of the article we explained that the classic “Best-Practices” benchmarks do not usually apply to “30-Minute” EDs, and we used the example of Left Without Being Seen, this does not imply that they must not be followed. As long as these metrics are being compared to those of other operationally efficient EDs they can still give you significant information about your intrinsic efficiency. For example, although operationally efficient EDs keep patient Leaving Without Being Seen under 0.5%, if such a department suddenly goes above that number this should raise a “red-flag”. In addition, in all reportable quality measures (i.e. “Core-Measures”), “30-Minute” EDs fare better than most other emergency departments due to timely identification of requisite pathology and a more controlled work environment that prevents errors of omission.

In conclusion, the importance of strict adherence to the stated metrics above cannot be understated. A focus on operational efficiency demands that these metrics be attained and, in particular, that Non-Admit Throughput times be kept below 180 minutes. To illustrate, imagine an ED that sees 72,000 patients a year and has Non-Admit Throughput Times of 230 minutes. If it admits 20 % of their patients that means this department discharges 160 patients a day out of an average daily census of 200. Decreasing Non-Admit Throughput Times to 180 minutes represents an average of 133 hours a day or 4,000 hours a month reclaimed from what was previously non-productive or idle time. These 133 hours is essentially the “penalty” this department pays for its operational inefficiency every day.

Obviously, Emergency Departments utilize many metrics and benchmarks to track performance. The purpose of this post is not to list them all but emphasize those essential to operationally efficient EDs while providing a standard whereby future implementation strategies can be analyzed and compared.

Emergency Room Efficiency Blog

2009-01-29T14:06:00.002-05:00

Using the words Emergency Room and Efficiency on the same sentence is usually considered an oxymoron...nevertheless, this is not so in every instance...

There are hundreds of Emergency Departments in the United States that have transformed their operational models and become not only extremely efficient at managing patient flow but that have attained "world-class" metrics overall...

I have been personally involved in helping set-up several of these operationally efficient Emergency Departments throughout the country over the last 6 years...

This blog will concentrate on the study, explanation and decoding of what makes these operationally efficient Emergency Rooms work and the system-wide issues that must be addressed to implement them...

I will be posting periodically so please check frequently for new posts, articles and resource links...