Urgent need for emergency department optimization

Hospitals are under regulatory pressure to reduce emergency department (ED) costs, improve efficiency, and increase throughput capacity, which ultimately impact hospital revenue and patient satisfaction scores.

As such, the ED has taken on a more prominent role as it interfaces with every department of the hospital and healthcare system in some form, impacting the patient healthcare journey overall. These key factors are driving the urgent need for ED optimization.

Nobody is having a good day when they go to the emergency department. The goal of ED optimization is to improve performance and quality measures while enhancing the overall patient experience. However, implementing best practices is not easy when EDs are similar but not identical, and each day and each patient case has commonalties but is rarely standard.

Key Metrics in Delivering Emergency Care
While every ED may be different in terms of volume, physical structure, staffing, and community/population needs, the metrics for measuring its effectiveness are not. A key driver for optimization is addressing regulatory mandates and improving performance metrics, which include:

Left Without Being Seen (LWBS) – low LWBS rates increases revenue for most EDs, helps to reduce safety risks and supports positive community perceptions;
Arrival to Provider – a key metric that leads to early assessment and intervention, helps mitigate risk, and is a key patient satisfaction driver;
Length of Stay (LOS) for Discharged and Admitted Patients – an important metric for reimbursement and patient satisfaction as well as a key driver for increased capacity;
Decision to Admit – this metric reflects the ability of the ED to provide timely admission to an inpatient bed with standardized coordination, communication, and collaboration across all lines and is a key driver to HCAHPS scores.
Patient Satisfaction – largely based on the admitted patient's overall experience, the ED processes can affect HCAHPS scores with about 60% of inpatients beginning their experience in the ED;
Revenue Increase – implementing best practices and innovative processes that decrease LWBS and LOS metrics and improve the patient experience helps support increased revenue, more positive community perception, and potential growth for the hospital.

Three Key Steps for ED Optimization
Data –in and of itself– is not the remedy nor does it provide the complete picture of an ED's performance. To be effective, data must be combined with assessment, observation, and analysis of the ED and how the staff works within it. Information must be effectively integrated within the ED and across the hospital. The approach to optimization generally focuses on three key areas: 1) front-end flow, 2) back-end patient disposition and discharge, and 3) integrating patient experience strategies.

Step One: Improve the Front-end Flow
The first step in ED optimization is always to focus on the front-end process of arrival and triage/assessment. Triage is the process of rapidly assessing and sorting patients to provide the right care, in the right priority order, and with the right provider to have the most positive outcome. These processes are intense and require a high skillset to perform the process effectively and efficiently. Managing triage acuity levels is of the utmost importance in delivering emergency care and is really the 'art and science' of emergency nursing. The goal of optimization of front-end efforts is to get the patient to the provider for care as quickly as possible. This optimization of the triage processes also decreases patient "walk-a-ways" so the hospital captures additional revenue by treating more patients overall, both those that will be discharged from the ED and those that may incur a hospital stay.

Case in Point: Lower Walk-out Rates Drive Patient Satisfaction and Revenue1
A 408-bed community hospital with a history of high ED walk-out rates and multiple process improvement attempts to resolve the issues was failing at maintaining acceptable rates. The 68,000-annual-visit ED had tried a series of rapid improvement events (RIEs). The implementation of these initiatives was not consistent or sustained, resulting in minimal impact on LWBS and patient satisfaction.
Working with a strategic partner, the hospital was able to greatly reduce arrival-to-triage times as well as improve arrival-to-room by 37% and arrival-to-provider by 44%. Subsequently, patient satisfaction rates increased 334% to the 100th percentile and the likelihood of recommending the ED increased 109% to the 88th percentile. Most importantly, the hospital was able to decrease LWBS by 41%, which generated over $1.2 million in collectable revenue annually.

Step Two: Manage Admission Patient Volume Better
The second key step focuses on back-end processes from the decision to admit until the patient is placed in an inpatient bed. Many hospitals struggle with limited inpatient capacity, hospital length-of-stays, and competition for the beds with higher ED and surgical/procedural volumes. As a result, emergency department crowding and boarding is common. Several areas are critical to improving the ability to manage patient volume including more consistency with patient admission and discharge practices, coordination between the ED and other departments, and standardization of bed management. Process improvements can help increase access to available beds and streamline bed management processes in order to move patients through the ED and hospital more effectively.

Step Three: Integrate Patient Experience Strategies
The third step is the integration of the patient experience into all facets of the performance improvement efforts. This involves ED staff and provider education programs that focus on specific patient-centered tactics while increasing efficiency and effectiveness of care as well as enhancements to the patient environment. It is important to first understand the patient's journey in the ED and evaluate the clinical environment from a holistic perspective. Utilizing a data-driven and structured approach, healthcare providers can more readily pinpoint issues and begin to effectively align clinical workflows, technology, and resources to create long-term strategies for improvement.

ED Optimization Benefits
The patient experience in the ED has a significant impact on HCAHPS scores. There is research to support the correlation between the perceived care by an admitted ED patient and how that patient responds to his/her satisfaction survey once discharged from the hospital (American College of Emergency Physicians, Patient Satisfaction, June 2011). If the patient has a negative experience in the ED they will rate care lower, which is driving the c-suite to improve the patient experience in the ED. By equipping staff with the tools and support for respectful, informative interactions with patients, hospitals can increase patient recommendation and loyalty scores.

About the authors

Mark Feinberg
Managing Partner, Philips Blue Jay Consulting

Mark has more than 25 years of experience in healthcare, leading client engagements focused on operational effectiveness, patient throughput, supply chain optimization, pharmacy improvement, case management, interim ED management, and perioperative services. He brings a critical eye and significant management expertise to each project. He co-founded Blue Jay Consulting in 2006, which was acquired by Philips in 2015. Trained as an emergency medical ambulance technician, Mark holds a master's degree in business.

Suzanne Stone-Griffith, MSN, RN, CNAA
Principal, Philips Blue Jay Consulting

Suzanne brings a wealth of healthcare experience, with expertise in metrics and performance improvement. She led the development of the largest automated and integrated ED database for HCA and created the HCA ED Playbook which served as a process improvement roadmap for every ED in the country. She holds an MSN and a BSN, as well as being Lean Certified, a master trainer for Team STEPPS and chairman/co-chair of three prestigious healthcare panels.

1 The data in this case study is available in Interim leadership improves patient satisfaction and throughput metrics (Philips publication #4522 991 17931). Results from case studies are not predictive of results in other cases. Results in other cases may vary.

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