Emergency Department Quality Improvement: Transforming the Delivery of Care

January 11, 2019

Article Summary

Overcrowding in the emergency department has been associated with increased inpatient mortality, increased length of stay, and increased costs for admitted patients. ED wait times and patients who leave without seeing a qualified medical provider are indicators of overcrowding. A data-driven system approach is needed to address these problems and redesign the delivery of emergency care.

This article explores common problems in emergency care and insights into embarking on a successful quality improvement journey to transform care delivery in the ED, including an exploration of the following topics:

• A four-step approach to redesigning the delivery of emergency care.
• Understanding ED performance.
• Revising High-Impact Workflows.
• Revising Staffing Patterns.
• Setting Leadership Expectations.
• Improving the Patient Experience.

This article is based on a 2018 Healthcare Analytics Summit (HAS 18) presentation given by Linda Hummel, MS, BSN, RN, Vice President of Quality and Patient Safety at Mission Health System and Rick Lee, MSN, RN, CEN, NE-BC, Executive Director of Emergency Services at Mission Health System, entitled “Transforming Emergency Care with Analytics and Technologies.”

More than half of all U.S. hospitals report over-crowding in the Emergency Department (ED), one-third report an increase in ambulance diversion, and 90 percent report they frequently operate at or over capacity, risking the ability to effectively provide emergency care to those who need it and contributing to patient dissatisfaction. Overcrowded EDs cause problems for both hospital patients and staff, such as increased wait times, length of stay (LOS), medical errors, and mortality rates, as well as financial losses to hospitals. A data-driven systems approach can dramatically improve every aspect of emergency care, improving wait times and throughput, reducing left without being seen rates, and improving patient satisfaction.

Common Problems with Emergency Care

Crowding in the ED has become a widespread problem in hospitals across the country for two primary reasons: emergency medicine is the only specialty with a federal mandate to provide care to patients seeking treatment, and a shortage of primary care providers has forced more sick people to seek treatment in hospital emergency rooms. This overcrowding leads to a number of common problems with emergency care that can be seen as markers of hospital health.

These include the following problems with emergency care:

  • Patients walking out of the emergency department without being seen. When customers vote with their feet, this presents three risk factors for the organization:
    • Customer satisfaction – anytime a patient walks out the door without having received the service she came in for, customer satisfaction suffers.
    • Health – The patient did not see a provider to be evaluated for the health problem that brought him to the ED leading to potential negative healthcare outcomes down the road.
    • Financial – Each patient that leaves without being seen represents a missed financial opportunity to provide a needed service.
  • Excessive wait times. In May 2014, the Centers for Disease Control and Prevention (CDC) reported average emergency department wait times were roughly 30 minutes.
  • Volumes negatively impacting throughput and patient experience. Hospitals need a coordinated system effort in order to improve throughput, however Emergency Departments can focus on some specific metrics such as Median LOS for discharged patients, Median LOS for admitted patients, and Median LOS for behavioral health patients to improve throughput and patient experience. However, factors such as operating room schedules, inpatient capacity, and increased behavioral health problem affect volumes and throughput and need to be addressed on a system-wide level.

Redesigning the Delivery of Care Through Emergency Department Quality Improvement

As the crisis of emergency care grows, hospitals have more pressure to make improvements in addition to the many other pressures facing the healthcare industry. Redesigning the delivery of emergency care involves a four-step approach.

  1. Begin with the bigger aim and ask “What do we need to best deliver emergency care?” Improving emergency care ties into the Triple Aim of healthcare improvement: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare.
  2. Create a vision and support for a data-driven systems approach to improving emergency care. Many times, a department will embark on an improvement project, but don’t think about how it will affect the flow of other teams or departments. Instead, it can be helpful to create an ED Joint Practice Team where anyone who touches the patient is part of the care team. This helps improve communication between departments to avoid unforeseen consequences of changes to other departments.
  3. Using an analytics platform, develop an ED analytics application that provides insight into performance. If an ED with 65 beds has 130 patients come through the doors on any given day, but the OR doesn’t know, nor does the hospital care control center, the ED is operating in isolation without the ability to resolve issues or foresee them in advance. Using an analytics application such as ED Explorer, frontline leadership and executives have the ability to track throughput, and obtain actionable data necessary for demand/capacity management.
  4. Engage frontline staff, key stakeholders, patients, and families in improvement. Improving ED throughput is much more than an emergency department initiative. It must include the entire system of care for real, lasting change to occur.

Understanding ED Performance

To prevent the ED from operating in isolation, it’s necessary to involve hospital leadership and other frontline leaders in the improvement process. One way to do this is utilizing executive dashboards that show a snapshot of the ED performance on a regular (perhaps daily) basis. Dashboards might show the C-suite how many patients are in the ED, how many are waiting to be seen, wait times, and the number of behavioral health patients. One of the most telling metrics used in an executive dashboard is the longest wait time recorded or the longest wait time for a bed to be assigned to an admitted patient in the last 24 hours. Using executive dashboards can help keep stakeholders informed and involved. Increased leadership visibility and engagement can greatly contribute to success.

In addition to the daily snapshot, executives might be given access to look ED goals, past performance, patients left without being seen percentage, and admission trends. Using an emergency services application such as ED Explorer can help provide the data necessary to track, trend, and predict resources need in the delivery of quality emergency care. Additionally, a robust ED analytics application allows users to identify and quantify areas of opportunity in throughput, ancillary resource allocation, utilization, and quality.

Emergency department quality improvement - Sample snapshot of ED Explorer analytics application
Figure 1: Snapshot of ED Explorer analytics application that provides multiple views of data for the efficient day-to-day Emergency Department operations.

What using an analytics application does is help users understand ED performance based on data. That data can then be used to predict and improve performance. For example, using analytics, ED leaders can better understand patient arrival times and their impact on ED throughput. This data can be surprisingly predictable. For instance, a hospital might find that if 30 or more patients arrive within one hour of each other, ED wait times skyrocket up to two hours. Then, if 30 or more patients are checked in within an hour, the analytics application can notify relevant stakeholders and departments about surging volumes in the ED. If the ED is the frontline, the imaging department might be the next department to experience large volumes–and wait times as a result. Additionally, notifying the relevant people can result in increased staffing when needed and prevent further congestion in other departments.

Revising High Impact Workflows

In looking to tackle Emergency Department quality improvement projects, hospitals should look for high-impact opportunities. Revising high impact workflows such as streamlining registration and provider triage can have real, impactful results on ED wait times, patients left without being seen percentage, and patient experience. Some of the workflow areas to focus on include the following:

  • Improved triage workflow.
  • Provide earlier access to provider using a triage advanced practitioner.
  • Redesign discharge process to reduce non-value-added time.
  • Implement readiness huddles.
  • Improve response to surges in patient volume.
  • Revise staffing patterns.
  • Add flow coordinator during busy times to oversee hospital patient flow.

Revising Staffing Patterns

With a robust analytics application, Emergency Department leaders can gain valuable insights into improving staffing patterns to maximize efficiency. What department leaders need to ask is “Do we have the right amount of staff at the right times in the right places?” What hospital leaders might be surprised to learn is that ED volumes can be surprisingly predictable. Using an analytics platform, healthcare leaders can gain use following insights into volumes to help inform their staffing patterns.

  • Identify seasonality in volume trends.
  • Identify weeks with consistently high-volume.
  • Utilize this data to predict upcoming high-volume periods.
  • Adjust staffing matrix to meet trends.
  • Use historical trends to plan for holiday or other identified periods of high census.
  • Use historical trends to open and close sections of the ED to align with demand.

One hospital found that the busiest day of the year was the Monday following Super Bowl Sunday during a retrospective three-year review of ED census. Having access to this data and the ability to use it to identify trends, understand and respond to surges in volume, and predict the resources needed help improve the efficiency and quality of care provided in Emergency Departments.

Setting Leadership Expectations

Communicating leadership expectations is a crucial component of success. Because ED performance is a key indicator of hospital health, it’s necessary for hospital leaders to be actively engaged in the department and its improvement efforts. It may be helpful to identify an executive such as the Chief Nursing Officer or President of Quality and Safety as an Executive Sponsor for the improvement work. Additionally, it’s important to keep executives informed and involved through daily rounding, participation in surge calls if needed, and receiving daily ED performance reports.

Improving the Patient Experience

As healthcare becomes more patient-centric, it’s more important than ever to improve the patient experience. According to Becker’s Hospital Review, improving patient satisfaction begins in the ED. In order to improve patient satisfaction in the ED, the quality of care must be consistent. Additionally, hospitals must purse patient feedback in order to identify high impact areas of focus. Below are some ideas for improving the patient experience in the ED:

  • Facilitate weekly huddles to review patient feedback.
  • Ensure leadership makes clear that patient experience is a priority for the entire team.
  • Exchange security FTEs for “Guest Services.”
  • Conduct patient experience training.
  • Consider embedded care management in the ED.
  • Have leaders perform daily rounds.
  • Reinforce common patient experience best practices and expectations.

Getting Results

Mission Health faced a number of challenges in its ability to deliver effective emergency services. Large numbers of patients were walking out of the ED without being seen by a provider, and, on average, patients waited more than 50 minutes to see a qualified medical provider. They embarked on an Emergency Department quality improvement mission to improve their patient flow, patient experience, and ED throughput with a data-driven approach. In a little over one year, they dramatically improved all aspects of ED throughput, including:

  • Nine percent relative reduction in the rate of patients who left without being seen (LWBS), resulting in the current performance of 0.4 percent.
  • 29 percent relative reduction in the time from discharge order to ED departure time.
  • 24 percent relative reduction in the median length of stay (LOS) for patients who are discharged.
    • Changes in triage and treating patients who are not as acutely ill in a more space-efficient environment also contributed to a decreased LOS. With these changes, patient satisfaction doubled.

Embarking on an ED Transformation

Although improving care in the ED is a high priority for many hospitals, it’s important to have realistic expectations and prepare for success. Emergency Department quality improvement is a journey that takes time and improving ED performance is much more than an emergency department initiative–it must involve the entire system of care. Additionally, using a data-driven approach can help engage stakeholders and make a compelling case for change. Changing the entire system of care requires excellent leadership and leaders need to pace themselves so they can effectively lead the change.

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

  1. Seven Features of Highly Effective Outcomes Improvement Projects
  2. Healthcare Project Management Techniques: A Pragmatic Approach to Outcomes Improvement
  3. How to Achieve Your Clinical Data Analytics Goals
  4. The Top Seven Healthcare Outcome Measures and Three Measurement Essentials
  5. How UPMC and Health Catalyst Improve Outcomes Using Innovation in Activity-based Costing

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