Perspectives: Achieving Success in an Increasingly Complicated Environment

Achieving Success in an Increasingly Complicated Environment: Key Strategies to Improving ED Patient Flow

Success in emergency departments (EDs) is no longer defined simply by the delivery of timely and high-quality care that saves life and limb. In today’s competitive, consumer-driven environment, we are now assessed by our boards and our patients, on such things as optimal throughput rates, patient satisfaction scores and balanced budgets.

Indeed, the long list of issues demanding ED and hospital administrators’ attention means the juggling of priorities and resources. Where do we focus already limited assets to produce the most benefits? After 25 years of work in emergency medicine management and clinical care, the approach that I am convinced is of fundamental importance to success – and the one that I have made my specialty – is smooth patient flow.

It is no secret to the readers of this newsletter that smooth and efficient patient flow through the entire continuum of care is a key factor for ED and hospital success. Avoiding overcrowding and the host of problems it can create leads to a better experience and quality of care for patients and their loved ones, healthcare workers, and everyone else involved. It can also mean a more profitable institution – with less money lost due to time spent on diversion, and fewer patients leaving without being seen.

The benefits of ensuring that ED operations flow smoothly from the very beginning of the patient visit has a huge impact on subsequent steps in the system. While there is no magical solution to ED flow problems, through my experiences as Chair of the Institute for Healthcare Improvement’s Improving Flow Through Acute Care Settings team and partner to hospitals with BestPractices, there are a few key strategies that I convey to ED and hospital administrators.


Understand Your Demand and Capacity

The first step is to understand and track what your demand and service capacities are. By examining and understanding  demand and capacity data, hospitals should be able to assess  the following: 1) How many patients are entering the system, 2) When, where, and why they are doing this, 3) What  resources are required to treat them, and 4) Whether the capacity exists to do this effectively. Without this fundamental information, one has little real understanding of the situation and how to optimize patient flow. After all, as the old adage goes, you can’t manage what you don’t measure.

From McDonalds to Starbucks to the hospital ED, queuing and probability forecasting have long allowed us to reliably predict flow, and then align resources to meet it. All it takes is your data and a bit of simple number crunching to see the same repetitive patient flow curve day after day and month after month.

Once you have demand and capacity data, calculate your patient flow predictions down to the hour. This will give you a grounded understanding of where you stand and how to allocate resources to optimize operations and meet these demands.

Develop a Realistic Strategic Vision for Your Emergency Department

In trying to be all things to all people, many of our nation’s EDs have lost sight of what mission they really are on and what they can realistically accomplish. Sometimes, the unfortunate truth is that with limited resources and other operational impediments, an institution will never be able to succeed in all desired areas of performance at all times. In these cases, trade-offs must sometimes be made to ensure that the care being delivered is safe, efficient and high-quality.

Thus, as part of any improvement process, it is important that ED leadership step back and develop a clear “strategic vision” by asking two critical questions: 1) What is our mission as a department? and 2) How can we succeed at this mission with the resources available to us? Using the answers to guide your work, a shared strategic vision lays out clear and realistic outcomes that you can unite your team and institution behind.

Triage is a Process, Not a Place

Over the years, we have witnessed the role of ED triage burdened with a variety of new functions and responsibilities. The result is that what once was a simple and value-added screening point for patient intake has been effectively transformed into a complicated bottleneck and point of inefficiency in the ED. I would argue that most of these changes add little value to the triage process and can be performed better and more appropriately at other points in the patient’s visit.

Examining and reworking the triage system to remove these add-on functions is an important step in improving patient flow. The triage process is like a flywheel, setting the pace of patient flow throughout the institution. It should serve as a driver of the patient and processes along the continuum of care rather than an impediment to smooth operations. An ideal triage process should do nothing more than identify patient needs and disease/injury severity in four to five questions, so that patients can be segmented into diagnostic and treatment lines and matched to resources (space, staff, supplies, and services) within the institution.

This isn’t an unknown concept to hospitals – in fact, many already practice  some form of patient flow segmentation through triage procedures, such as identifying “critical care” or “fast-track” patients. What few hospitals and EDs have is a proven, standardized assessment model with clear and reliable system practices to support it.

The most efficient and effective model for patient segmentation is the five-level Emergency Severity Index (ESI) system (or the Canadian equivalent-the CTAS system). Assessing and segmenting patients into one of five streams – ranging from a Level-1 patient requiring critical, life-saving care to a Level-5 patient with far less urgent needs – is recommended because it is easy to understand, implement and teach to ED teams. Once in place, it can be easily applied to all clinical situations, and allows for efficient patient processing and treatment.

It is not enough, however, to simply assess a patient and put him or her back in the queue. Standard operational procedures and processes to manage segmented patient flows after triage is performed must be established to keep the system operating efficiently. Currently, the purpose of most segmentation-style front-end ED practices is to determine how long a patient can safely wait before he or she moves through the system. In order for this to work, assessed patients must be ushered to and through the next steps in their journey in a timely manner.

A good segmentation system should be supported by a fully staffed and smoothly functioning “fast track” system that can quickly handle non-urgent patients. This allows the rest of your ED to be optimally focused, operate more efficiently, reduce wait times and limit waiting room overcrowding. Reworking your triage practices and patient intake by implementing a patient flow segmentation model will give you a best-in-class intake system that is built to support smooth patient flow.

Remember: Change Takes Time, Effort and Innovative Strategies

The ability to develop and implement interventions that perfect operations is something that the U.S. health care system has always been good at. From fast-track triage to always-ready catheterization labs, we have done a fantastic job at tackling the myriad of problems that affect ED patient care. The result is the potential for a modern emergency care system that we can be proud of and comfortably rely upon – not just for our patients, but also for our own family and friends.

Sometimes lost in this innovation, however, is the understanding that achieving improvement in areas like patient flow takes time, effort and innovative strategies. If there were quick and easy solutions to these problems, EDs nationwide would have already implemented them. Tackling system change is a fundamental, long-term undertaking that will require sustained commitment from everyone involved.  But as I have witnessed over the years, by utilizing the strategies outlined here, and sustaining execution over time, hospitals can successfully achieve smooth patient flow.

Kirk Jensen, MD,Chief Medical Officer, BestPractices, Chair of the Institute for Health Improvement Improving Flow through Acute Care Settings team, Chair of the IHI Operational and Clinical Improvement in Emergency Department team, Rocky Mount, N.C.