Once a hospital has formed a patient flow improvement team (Section 2) and is collecting performance data (Section 3), the next step is to identify a strategy or strategies to reduce emergency department (ED) crowding and improve patient flow. Selecting the right strategy is paramount for any successful intervention. Hospitals that devote enough time up front to careful strategy selection often save time in the long run by avoiding the need to perform major adjustments midstream. This section is designed to walk you through the processes of selecting a strategy.
1. Identify the Most Likely Causes of the Specific Problems You Face
Members of your patient flow improvement team should be able to identify possible roadblocks to patient flow in the ED and the hospital. Is the lab turnaround time contributing to long patient lengths of stay in the ED? Do patients typically wait for hours for a physician specialist consult? Performance improvement methodologies (e.g., Lean, Six Sigma) and related tools (e.g., process mapping) can be used to identify specific causes of blockages, as well. Roadblocks also may be identified through a review of data from your hospital. Identifying the major roadblocks to flow should guide your team in focusing your improvement efforts.
Example 4. Good Samaritan Hospital: Using Data to Aid Strategy Selection
Good Samaritan Hospital in Long Island, NY, had a rate of left-without-being-seen (LWBS) patients that was close to the national average of 2 percent. After reviewing its data, ED leaders found that 87 percent of LWBS patients were triaged as Emergency Severity Index (ESI) Level 3, and the highest LWBS rates occurred among a subset of ESI 3 patients presenting with one of the following six chief complaints: abdominal pain, flank pain, headache, pregnancy complication, vaginal bleeding, or vomiting. The average LWBS rate among that group was 12.5 percent. Further, this subset of ESI 3 patients had an average length of stay of 426 minutes, compared with an average of 294 minutes for all ED patients.
In addition to having the highest LWBS rates, this subset also had the longest physician wait times—the median time was 78 minutes, compared with 48 minutes for all ESI 3 patients. Part of the reason for these higher LWBS rates and longer waits was that these patients fell in the middle: they had complaints too complex for fast track yet not serious enough for direct admission to the ED. However, the potential for these conditions to become life threatening while the patient waits to be seen is a major patient-safety and quality-of-care concern.
To address this identified problem, Good Samaritan implemented a strategy to immediately direct a subset of ESI 3 patients to a dedicated physician and nurse practitioner. Following a physician evaluation in triage, patients are received by a nurse practitioner who coordinates their care with the triage physician.
2. Explore What Other Hospitals Have Done to Improve Patient Flow
Numerous resources are available online that describe actions taken by hospitals that have been successful in improving patient flow (go to Appendix A). These resources should help your team generate ideas for possible strategies.
3. Consider Your Resources
Your team needs to set realistic expectations for your strategy. How ambitious can it be and still be successful? A lack of human and financial (e.g., capital, educational) resources is often a barrier that eliminates many otherwise attractive strategies from consideration. For example, hospitals with access to additional staffing or full-time equivalents (FTEs) may be able to adopt strategies that add new roles. Hospitals with access to educational funds may be able to adopt strategies that are facilitated by current staff with enhanced skills.
The likely need for additional resources points to the importance of securing leadership support—perhaps the most precious resource of all. Without an administrative champion, it can be extremely difficult to secure needed funding. Hospital leaders may be willing to provide funding support for your efforts if you can make the case that your strategy will lead to an increase in patient revenue through a reduction in the number of patients who leave without being seen and/or in ambulance diversion hours. In addition, leadership support makes it more feasible to consider changes that impact units and staff outside the ED. If you do not have committed leadership support, your team would do best to restrict its focus to process changes within the ED, since these generally require few, if any, additional funds, and they do not require coordination with, or cooperation from, non-ED staff.
Example 5. St. Francis Hospital: Educational Resources Needed for Ambitious Strategy
St. Francis Hospital in Indianapolis, IN, realized that because of strong departmental nursing leadership and some successes with Lean Six Sigma projects, front-end improvements were attainable. At the hospital's south campus in January 2009, ED leadership selected the combined strategies of quick registration and rapid triage as projects to be implemented through the Urgent Matters Learning Network.
In late spring of 2009, two nursing educators formed an education subcommittee that was responsible for developing an educational plan for the process changes. This plan included presentations at staff meetings, one-on-one education, online training, huddles, emails, and educational folders. During staff meetings in August and September 2009, presentations included an overview of the educational folders, an update on staff education (75 percent of all nurses attended at least one educational session), and a review of the new triage process.
Concurrently, a significant number of nurses were trained in a standardized triage methodology. The ED director had previously been trained in this methodology, and another nurse leader was sent for train-the-trainer training in early 2009. These two trainers then trained ED staff nurses. Most RNs completed the 2-day training and passed the certification exam by the end of 2010. This new in-house training standardized the mechanical and cognitive concepts of the triage process and included both rapid and comprehensive triage training. The training costs were $7,000 for an additional in-house trainer and $80 for each nurse who received on-site training from a certified staff trainer.
4. Choose Your Strategy
Through Urgent Matters Learning Network (UMLN) II, we discovered that there are several processes hospitals can use to select a strategy, ranging from one person selecting the strategy to a large staff-level performance improvement team brainstorming various strategies, testing them (e.g., through kaizen events [i.e., a continuous quality improvement process] or rapid cycle change), and finally coming to a decision. In general, the selection process usually fits into one of two broad categories:
- Top-down strategy selection.
- Bottom-up strategy selection.
UMLN II hospitals were divided in the approach they used, with some hospitals primarily using a top-down approach to strategy selection and others using a more bottom-up approach. Top-down selection normally includes the ED leadership team (in one case through a vote of senior leaders), although it can also include hospital leadership. Bottom-up selection often occurs at hospitals that use performance improvement methodologies, such as Lean, that emphasize bottom-up improvement.
Example 6. Thomas Jefferson Hospital: Selecting a Strategy Through the Ballot Box
ED staff from Thomas Jefferson Hospital in Philadelphia, PA, reviewed the UMLN II toolkit, printed all the strategies from the toolkit, and distributed them to the ED leadership group. Members of the leadership team voted anonymously from among the 49 listed strategies. Based on the vote, three strategies were identified for further consideration. One strategy was eliminated because the hospital already had a program in place to address the particular problem. A second was eliminated because the leadership team determined that implementation of the strategy was partially out of its control. The remaining strategy was improving the fast track, which became the focus of the hospital's improvement team.