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EMPATH's Tampa Bay Area Client Describes ED Transformation
A Change in Culture at St. Joseph's Hospital ED
By Charles Sand, MD
Each week, I read reports about how emergency
departments across the country fix their operations.
They put in a new triage system, board patients in an
inpatient unit hallway, or deploy numerous other isolated
improvements that achieve small "hits." These
"hits" are often temporary, as we all have experienced.
Yes, they are successes, but success that is, at best, limited
without fixing entire operational problems.
The hospital where I practice, St. Joseph's in
Tampa, undertook a project of significant scope and
outrageous goals. This was to be a "cultural transformation"
project that would affect nearly every patient
care provider in the emergency department, inpatient
units, and supporting ancillary services.
Many of us had our usual healthy skepticism when
we heard the project's goals. We would reduce ED
length of stay by 30-50%, decrease the number of
patients leaving before evaluation by 90%, eliminate
ambulance diversion, and increase ED and inpatient
volume by 15-20%. And it would be much more
organized and much less noisy in the ED.
But what we have done turned out to be as significant
as the goals were a stretch. Over the past year, our
ED has undertaken a project that addresses the delivery
of quality patient care as a hospital-wide issue. We
have broken down silos – those barriers between
departments – to create accountability and shared
responsibility, as well as solutions, across departments
hospital-wide.
With the assistance of EMPATH Consulting, we
put into place redesigned patient care processes for virtually
every aspect that delays patient movement, diagnosis,
or treatment. From the point where a patient
walks into the ED until discharge or admission, we
redesigned our processes. We work in zone-based teams that are committed to achieving performance
targets as well as to backing up other teams as needed.
We have high-census protocols which kick in at predefined
levels of work activity.
Every process has interlocking accountability.
Each end of the process has an owner, and those owners
take joint responsibility for successful completion
of that process.
For example, when a team member brings a patient
back to a bed, s/he is also responsible for ensuring that
the ED physician gets to that patient in the targeted
time. When an ED patient is ready to be admitted, the
ED staff "push" the patient to the inpatient floor and
the inpatient staff, having pre-planned their work
activity, "pull" the patient from the ED. When the lab
gets an order from the ED, the nurse and phlebotomist
are jointly responsible for meeting targets – specimen
collected and received in the lab, tests run, results produced.
With new, specialized technology systems installed
for this project, we now measure every process and
time stamp critical to patient flow. We, and others
monitoring the ED, know our performance – nearly
real-time – with web-based monitoring systems available
at any workstation, and even from home. This
real-time capability allows us to identify the first signs
of process breakdown, to make decisions to prevent a
surge capacity crisis from occurring, or to quickly
resolve issues in the early stages. Through hundreds of
dashboard reports, we can monitor performance on a
weekly basis. Predefined, standardized action plans
have been designed to improve any process which
does not meet its targeted performance.
But probably most importantly, leadership is committed
to holding staff accountable for the project's
continued success and to sustaining our results. As we
are all well aware, without both committed hospital and
ED leadership, any project will be just another in a long
line of temporary improvement initiatives.
During the past year in this project, we have seen
an increase in ED volume of 4.8%, and ED patients
admitted to the hospital of 9.4%. We virtually eliminated
ambulance diversion – over 25 hours per month during
June-November of 2007. Also during this past year,
ED patient satisfaction has risen from the 13th to the
89th percentile, and is still climbing.
Other performance improvements (March-
November 2008) include:
We see over 340 patients a day in our ED and are
currently on pace for an increased volume to around
125,000. Not infrequently, we have 120-130 patients in
the department at any one time. This includes acuity
that would rival any ED, with over a thousand Trauma
Alerts, a thousand Stroke Alerts, and approximately
400 STEMIs this year.
We used to have constant long waits in the lobby
and significant numbers of patients boarding in ED
beds and hallways, with many resultant unhappy, frustrated
patients and staff. Now, seeing even more
patients, we have minimal waits, fewer patients leaving
before treatment, and much greater patient satisfaction
and improved patient/staff interactions.
Patient care has truly improved from many aspects.
Not the very least is that we now have minimal delays
in relief of patient discomfort, and earlier diagnosis and treatment of both "run of the mill" medical conditions
and of "hidden disease," the latter with its not infrequent
deterioration as patients sit for hours in the waiting
room and in ED beds waiting for the ED doc to
evaluate and treat them.
Due to a phenomenal and highly committed team
effort from the hospital and ED leadership – and especially
all of our hard working physicians, ED group,
and ED staff team members – we have seen a significant
"change in culture." Ultimately, improvements in
our entire system operations are more long-lasting, and
the hospital and ED have become more efficient than
we have seen with previous "piece-meal" attempts at
performance improvement.
Overall, the improvements have enabled the hospital to provide more efficient, reliable service and to increase its standing in the community.
And yes, despite seeing more patients at a faster pace, things are incredibly less noisy in our ED than a year ago. A change in culture has indeed occurred at St. Joseph's Hospital.
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