Improving Patient Flow and Reducing Emergency Department ...

[Pages:48]Improving Patient Flow and Reducing Emergency Department Crowding:

A Guide for Hospitals

Improving Patient Flow and Reducing Emergency Department Crowding:

A Guide for Hospitals

Megan McHugh, PhD Kevin Van Dyke, MPP Mark McClelland, MN, RN Dina Moss, MPA

October 2011 AHRQ Publication No. 11(12)-0094

This document is in the public domain and may be used and reprinted without permission.

Suggested citation: McHugh, M., Van Dyke, K., McClelland M., Moss D. Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals. (Prepared by the Health Research & Educational Trust, an affiliate of the American Hospital Association, under contract 290-200-600022, Task Order No. 6). AHRQ Publication No. 11(12)-0094. Rockville, MD: Agency for Healthcare Research and Quality; October 2011.

The opinions presented in this report are those of the authors, who are responsible for its content, and do not necessarily reflect the position of the U.S. Department of Health and Human Services or the Agency for Healthcare Research and Quality.

Acknowledgments: The authors would like to express their sincere gratitude to the patient flow improvement teams from the hospitals that participated in the Urgent Matters Learning Network (UMLN) I and II:

Grady Health System Atlanta, GA

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Boston Medical Center Boston, MA

University Hospital San Antonio San Antonio, TX

University of California at San Diego San Diego, CA

Henry Ford Hospital Detroit, MI

Thomas Jefferson University Hospital Philadelphia, PA

Elmhurst Hospital Center Elmhurst, NY

Hahnemann University Hospital Philadelphia, PA

Inova Fairfax Hospital Falls Church, VA

Stony Brook University Medical Center Stony Brook, NY

BryanLGH Medical Center Lincoln, NE

Good Samaritan Hospital Medical Center Long Island, NY

The Regional Medical Center at Memphis Memphis, TN

St. Francis Hospital Indianapolis, IN

St. Joseph's Hospital & Medical Center Phoenix, AZ

Westmoreland Hospital Greensburg, PA

The authors also thank the contributors who provided important feedback on this guide, including representatives from: Shore Health System, Easton, MD; UMass Memorial Medical Center, Worcester, MA; and Baptist Health Care, Pensacola, FL.

Contents

Executive Summary ........................................................................................................................................1 Section 1. The Need to Address Emergency Department Crowding ..........................................................5 Section 2. Forming a Patient Flow Team ......................................................................................................7 Section 3. Measuring Emergency Department Performance......................................................................10 Section 4. Identifying Strategies ..................................................................................................................14 Section 5. Preparing to Launch ....................................................................................................................17 Section 6. Facilitating Change and Anticipating Challenges ......................................................................23 Section 7. Sharing Results............................................................................................................................28 References ....................................................................................................................................................29

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Appendix A. Guide to Online Resources Successfully Used by Hospitals to Improve Patient Flow ............................................................................................................................31

Appendix B. Implementation Plan Template ..............................................................................................32 Appendix C. Example Implementation Plan ..............................................................................................37 Appendix D. Additional Readings ..............................................................................................................43

Executive Summary

The Need to Address Emergency Department Crowding

Although you, as a hospital or department leader, are responsible for overseeing performance across a number of dimensions, there are several reasons why addressing emergency department (ED) crowding should be at the forefront of your organization's improvement efforts:

1. ED crowding compromises care quality.

2. ED crowding is costly.

3. Hospitals will soon report ED crowding measures to the Centers for Medicare & Medicaid Services (CMS).

4. ED crowding compromises community trust.

5. ED crowding can be mitigated by improving patient flow throughout the hospital.

The purpose of this guide is to present step-by-step instructions for planning and implementing patient flow improvement strategies.

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Forming a Patient Flow Team

The importance of creating a patient flow improvement team--and giving careful thought to its composition--cannot be underestimated. Numerous studies have shown the benefits of creating a multidisciplinary team to plan quality improvement interventions. We recommend that, at a minimum, your team include a team leader (i.e., day-to-day leader), senior hospital leader (e.g., chief quality officer), ED physicians and nurses, ED support staff (e.g., clerks, registrars), representatives from inpatient units, and a research/data analyst. It is important to include representatives from all departments that will be affected by your strategy, individuals who will serve as champions for your strategy, and those who may oppose your strategy so that their concerns may be heard.

Measuring ED Performance

Measurement is a fundamental tool to identify and eliminate variation in clinical processes. Data also can be used to show that ED crowding is not just an ED problem, but one that requires hospital-wide solutions. Currently, hospitals are required to report several ED quality measures--for example, the core measures--and new measures are scheduled to start affecting hospital payment in 2013 and beyond (e.g., median time from ED arrival to ED departure). We recommend all hospitals begin collecting data on those measures now.

Identifying Strategies

Selecting the right strategy is paramount for any successful intervention. Hospitals that devote sufficient time up front to careful selection of a strategy often save time in the long run by avoiding having to make major adjustments midstream. We recommend that your team take the following steps before selecting your improvement strategy:

1. Identify the most likely causes of the specific problems you face. 2. Review available materials that describe what other hospitals have done to improve patient flow. 3. Consider your resources.

Preparing to Launch

Once the strategy is selected, we recommend that hospitals create a road map for the implementation process. An implementation plan should be completed by the team and can help:

1. Identify your goals and strategies. 2. Plan your approach. 3. Estimate the time and expenses associated with implementation. 4. Identify performance measures. Once completed, we recommend that you share your implementation plan with other hospital and department leaders to ensure that they (1) are aware of the efforts underway and (2) understand the timeline, budget, and resources that will be needed.

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Facilitating Change, Anticipating Challenges

Facilitating change often involves anticipating common challenges and taking steps to forestall them. We recommend several strategies for addressing those challenges.

Recommended Approaches to Addressing Implementation Challenges

Challenge

Recommended Approach

Rationale

Culture change Staff resistance Staff resistance

Constant reinforcement of the strategy by leaders

Staff education

Post-implementation adjustments reflecting user recommendations

Signals to staff that the improvement strategy will become standard procedure

Provides staff with the capabilities and knowledge to carry out the strategy

Signals responsiveness to staff concerns

Staff resistance, culture change, and lack of staffing resources

Lack of staffing resources Staff resistance

Use of Lean quality improvement methods

Robust data collection

Fosters a team environment

Provides concrete evidence of need for action; demonstrates success to hospital leaders and frontline staff; is crucial in securing an executive champion

Sharing Results

Sharing results internally and externally is the key to sustainability and spread. Widely reporting the results of multi-unit and department initiatives helps create a culture of transparency and openness. Units given the opportunity to compare their performance relative to other units will develop a healthy competition to improve. We recommend the use of ED dashboards to provide a snapshot of key process variables of particular interest to internal stakeholders.

Though not all hospitals can participate in a formal collaborative, we recommend that all hospitals build momentum by sharing their results with external stakeholders through community partnerships, written publications, and conference presentations. Some examples of potential outlets for sharing results include: community social service organizations that work with the hospital, other hospitals within a system or in the hospital's metropolitan or State hospital association, local newspapers and blogs, trade publications (e.g., Hospitals & Health Networks, Modern Healthcare), peer-reviewed journals (e.g., Joint Commission Journal on Quality and Patient Safety, Journal of Emergency Medicine, Journal of Emergency Nursing), and professional societies (e.g., Society for Academic Emergency Medicine, American College of Emergency Physicians, and Emergency Nurses Association).

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Section 1. The Need to Address Emergency Department Crowding

Many emergency departments (EDs) across the country are crowded. Nearly half of EDs report operating at or above capacity, and 9 out of 10 hospitals report holding or "boarding" admitted patients in the ED while they await inpatient beds. Because of crowding, approximately 500,000 ambulances are diverted each year away from the closest hospital. ED crowding has been the subject of countless news articles, lawsuits, and research studies.

Although you, the hospital or ED leaders, are responsible for overseeing hospital performance across a number of dimensions, there are several reasons why addressing ED crowding should be at the forefront of your organizations' improvement efforts. These include:

1. ED Crowding Compromises Care Quality

EDs are high-risk, high-stress environments. When capacity is exceeded, there are heightened

opportunities for error. The Institute of Medicine's (IOM's) six dimensions of quality (safety, effectiveness,

patient-centeredness, efficiency, timeliness, and equity) may all be compromised when patients experience

long waits to see a physician, patients are boarded in the ED, or ambulances are diverted away from the

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hospital closest to the patient. Over the past few years, several studies have presented clear evidence that

ED crowding contributes to poor quality care.1-5

2. ED Crowding Is Costly

In 2007, the most recent year for which data are available, 1.9 million people--representing 2 percent of all ED visits--left the ED before being seen, typically because of long wait times.6 These walk-outs represent significant lost revenue for hospitals. The same is true of ambulance diversions. A 2006 study at a large academic medical center (AMC) found that each hour on diversion was associated with $1,086 in foregone hospital revenues.7 A more recent study conducted at a different AMC showed that a 1-hour reduction in ED boarding time would result in over $9,000 of additional revenue by reducing ambulance diversion and the number of patients who left without being seen.8 A crowded ED also limits the ability of an institution to accept referrals and increases medicolegal risks.

3. Hospitals Will Soon Report ED Crowding Measures to CMS

The Centers for Medicare & Medicaid Services (CMS) announced the inclusion of five ED crowdingrelated measures under the Hospital Inpatient Quality Reporting Programa initiative:

n Patient median time from ED arrival to ED departure for discharged patients (calendar year [CY] 2013). n Door-to-diagnostic evaluation by a qualified medical professional (CY 2013). n Patient left before being seen (CY 2013). n Median time from ED arrival to ED departure for admitted patients (FY 2014). n Median time from admit decision time to time of departure for admitted patients (FY 2014).

aHospital Inpatient Quality Reporting Program. Overview available at .

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