According to the National Center for Health Care (NCHC), emergency department (ED) crowding has been a concern in U.S. hospitals for more than a decade. The Centers for Disease Control and Prevention (CDC) report the number of visits to EDs rose 19 percent from 1995 to 2005, even as the number of EDs decreased by 9 percent. Increased demand for ED treatment has a negative impact on both patients and care givers: Patients do not receive the care they deserve, and revenue is lost if patients are not treated in a timely manner.
Given this challenging issue in the ED, some forward-thinking hospitals are taking proactive steps to improve patient satisfaction and drive wait time down dramatically. Simpler Healthcare has worked with hospitals to implement lean management to achieve better results, and an excellent example of this is illustrated in the results Covenant Health System’s ED found.
Covenant Health System is part of St. Joseph Health System, one of the most successful nonprofit health systems in the United States. The system is comprised of four cornerstone facilities and a network of 14 managed community hospitals. With more than 5,000 employees, it is the largest health care system in West Texas and Eastern New Mexico, serving a 62-county area with a population of more than 1.2 million people.
Covenant Health System engaged Simpler Healthcare to coach staff on the application of lean management skills. The goal of the ongoing initiative is to empower employees with knowledge to provide better care and service to patients by eliminating waste and controlling costs.
The adoption of lean management practices by hospital staff has had a positive effect across the organization—particularly in the ED. As EDs across the nation wrestle with overcrowding and rising costs, Covenant Health System has leveraged lean management to treat more patients in less time, while maintaining and improving the quality of care.
“Treat and release” patients are patients admitted to the ED with noncritical injuries or complaints who will ultimately be discharged the same day. However, the patients typically wait long periods of time to be seen because critical patients—those with serious, potentially life-threatening injuries or symptoms—take precedence.
Not satisfied with the national standards of increasing length of stays, Covenant Health System sought to reevaluate its ED processes to get patients the proper care they need in the shortest period of time. The goal: improved patient care and decreased length of stay for all ED patients.
Carolyn Chisholm, the nurse manager of Covenant’s ED, and the ED Rapid Improvement Event team worked with Simpler Healthcare to evaluate the department’s flow processes and identified the following areas that could be improved:
• The Treat and Release pod’s operation hours started at 11 a.m., while patient arrivals to the ED began increasing about 9 a.m.
• There was only one room dedicated to treat and care for these types of patients.
• In the Treat and Release pod, only about 15 to 20 patients were being seen a day—about 8 percent of the total patients presented to the ED for care. The original average length of stay for these types of patients was about 162 minutes.
The ED staff recognized a need to streamline the process for the noncritical patient whose length of stay was longer due to high-acuity patients needing to be seen.
The ED brought together nurses, doctors, and staff who underwent a week-long, rapid-improvement event to learn lean management tools to help identify problems and find solutions quickly. Simpler Healthcare led members of the ED Rapid Improvement Event team in an intensive forum where new ideas to eliminate waste were implemented and went through a trial period. By engaging the key stakeholders in the process from the beginning, everyone took part in decisions, and understood why they were made, and had the opportunity to voice their opinion.
During the rapid improvement event, the following goals were set: to increase the number of patients treated in the Treat and Release pod and reduce the length of stay—from arrival to the ED through discharge.
To meet this goal, some new processes were outlined:
• In evaluating arrival times, it was determined that patients would be better served by increasing the Treat and Release pod’s operation hours to 9 a.m.–11 p.m.
• One additional room was created for the Treat and Release pod.
• A new waiting area was created for patients waiting to be seen in the Treat and Release pod.
“Adoption of lean management has led to a more positive atmosphere in the ED as physicians and nurses have been able see the number of patients treated increase, while their length of stays decrease,” says Chisholm.
Within two months the changes implemented at the Treat and Release pod began generating successful results on several levels. Highlights include:
By placing waiting room chairs directly outside the new treatment rooms, patients only have to walk 150 steps vs. 750 steps to receive treatment.
The average patient length of stay has dropped from 162 minutes to 130 minutes. Covenant is continuing to reduce the average wait time in its ED and is on track to reach its goal of a 90-minute average wait time—a 44-percent reduction.
The number of Treat and Release patients seen has increased from 8 percent of the ED total patient volume to an average of 20 percent within two months.
There is a more positive atmosphere among the ED staff members and physicians.
Patients treated have expressed an increased satisfaction with the new processes.
Since implementing lean management program, the ED is showing a 14-percent reduction in the cost per patient from 2007 to 2009. The average length of stay has been reduced by 57 percent.
This program is designed for these improvement efforts to increase patient volume, improve service quality, and increase annual revenues while not increasing costs. Based on the pilot results, current data projects a more-than $600,000 net revenue increase just from reducing the number of patients that leave without treatment. The ED is currently tracking a 17-percent volume increase over the last year—meaning more than 7,300 patients that would have left without treatment in a single year are now getting quality, timely care.
In addition, because other lean improvements dramatically improved operations from the ED to inpatient medicine, the hospital did not go on diversion during this peak season. This is what has allowed lower-acuity patients 50-percent less time in the ED, while simultaneously keeping more beds open for higher-acuity patients.
Since the implementation of lean management, productivity in the ED has risen more than 25 percent. Morale is increasing every day. The staff in the ED noticed that the key to improving employee morale is engaging everybody on what changes need to be made and then implementing lean processes that simultaneously improve patient care, reduce costs, and reduce the wastes in a process. The ED has learned that staff satisfaction is a key driver of patient satisfaction.
“The success found in the redesign of the Treat and Release processes has led us to want to redefine other processes in the ED, especially reducing the length of stay in the other ED pods and treatment areas,” says Chisholm. “We are currently discussing how we can use lean to accomplish our goals in these additional areas.”