Faster Turnaround Times Drive New "Express Care" Emergency Services

"We had a very good program and were doing a lot of good things," recalls Nancy McDonough, Manager of Quality Improvement. "But after ten years, we decided that we needed to move on to the next level. So we started looking at what we could do that would push us forward."

McDonough and her colleagues found the direction they were looking for in the Baldrige Criteria for Performance Excellence, the basis for the prestigious Malcolm Baldrige National Quality Award. With the enthusiastic support of White Memorial's executives, the hospital proceeded to use the criteria for a comprehensive self-assessment.

"We didn't score terribly well," says McDonough. "We saw it as a tremendous opportunity to improve in lots of ways. But we didn't know what to focus on."

She and her colleagues began searching for help and found it in Shaw Resources, a management consulting firm that helps organizations implement process management from the customer's point of view.

Identifying the Opportunity
"One of the first things we did when Jim Shaw came on board was to sit down with the directors and executives and identify the key processes," relates McDonough. Shaw defines a key process as any process essential to the organization's ability to meet or exceed customer expectations. White Memorial's executives and directors identified about forty. The next decision was: which ones should they concentrate on first?

With Shaw's help, the group prioritized their key processes according to their impact on customers (patients). After narrowing the field to three, the Emergency Department emerged as the one most likely to have the greatest impact in the near term.

There were several reasons for this. One was the high volume of patients seen by the ED, over 3000 patients a month. While the average daily discharge rate from the hospital was 30 patients, the ED was seeing 125 patients. Moreover, between 50 and 60 percent of the hospital's admissions came from the ED. So improvements in the ED would have a very high impact on patients.

Another factor influencing the decision was that White Memorial's business strategy called for increasing the number of nearby physicians using the hospital. Improving the ED was the most likely way to help achieve this objective because White Memorial's ED was, in effect, the hospital's "front door." About 35,000 patients (and their families) had passed through those doors in 1998. Improving service to ED patients would be a way of improving service to their attending physicians, too, and word would spread.

Establishing the Team
The next step was to establish a Process Improvement (PI) team, headed by a process owner. The team needed to be a cross-functional team, and representatives were recruited from all groups involved in the process of serving an ED patient: Admitting, Billing, Radiology, Laboratory Services, and so on. The director of the ED was designated the process owner. The team met every other week.

Breaking Down the Problem
A common stumbling block for beginning PI teams is the enormity of their charter. Improve the ED? Where should they start?

When the task is large, it helps to break it down into manageable pieces. White Memorial's PI team began by categorizing ED patients into three different groups:
Level 1-patients with non-critical problems such as earaches and sore throats that did not require intervention.
Level 2-patients who needed some intervention-antibiotics or an x-ray, for example-but who were not going to be admitted to the hospital. Level 3-patients admitted to critical care.

In selecting an initial objective, the PI team chose to concentrate on Level 1 patients. These patients were often kept waiting for hours while more seriously ill or injured patients were cared for. The team wanted to deliver health care services more efficiently to these patients without compromising the care of the more seriously ill or injured.

A New "Express Care" Initiative
As the team brainstormed ideas, attention focused on an area in the ED slightly off to one side, where three gurneys were kept. What if this area were dedicated to the exclusive care of Level 1 patients? Wouldn't this improve turnaround times?

The team decided to try. They designated the area as the "Express Care" unit. It would be open around the clock, with a dedicated doctor and nurse on duty from 12 pm to 12 am, the busier hours. The team added two chairs to the three gurneys and specified that these were to be used for Express Care patients only. When they were ready for business, the team set a goal: to see, treat, and release Express Care patients in 60 minutes or less.

Surprising Results
They are getting close. Turnaround times went from hours to minutes, currently between 70 and 75 minutes. In addition, the improvements resulted in some unexpected benefits, as well. In 1999, before the establishment of the Express Care service, 54 patients a month left White Memorial's ED without being seen. This number went down to 11 per month with the new Express Care service, a 70 percent improvement that increased revenue by $226,405. The number of unseen patients continues to drop and is now at 4 per month.

Another surprise was that as turnaround times for Express Care patients improved, so did the turnaround times for the other two categories of patients. The fear that the new Express Care service might compromise the care of other patients proved groundless. The opposite was the case.

It almost goes without saying that patient satisfaction increased dramatically. Not only did survey results improve, but also spontaneous compliments to the staff from appreciative patients.

More Ideas
Additional improvements made by the team include portable phones for ED physicians so that the ward clerk no longer had to track them down.

The team also installed a physicians' hot line for complaints and compliments. This should bring to the team's immediate attention any issues the patients' attending physicians have with the ED, such as a missing report or lab result. Not only will the hotline provide the ED with a chance to correct any errors or omissions quickly, it will also serve as an early warning system for defects in the ED's processes. Compliments are important, too. People need to know when they are doing something right.

Although not part of the original initiative, a new computer system is proving to be supportive of the team's efforts to improve service. The first phase of the new system, installed in December 1999, tracks a patient's passage through triage to bed to being seen by the nurse, treated by the doctor, and finally discharged. The patient receives a printout, in Spanish and English, with the diagnosis, the ED physician's name, the nurse's name, medications administered, and discharge instructions. In the second phase of the system, due to be up and running in March, the patient's attending physician will automatically be faxed a copy. Prescriptions will also be printed out, which will save time at the pharmacy and prevent errors.

In addition, the new computer system provides the PI team with data that was unavailable to them when data had to be collected manually. With technological support in place, the team is now setting some new goals. One is to deliver more timely pain management. Another is to conduct a point-of-service customer survey. The team will also be looking at ways to improve services to Level 2 and Level 3 patients.

A Refocus on Customers
Health care is not as predictable a business as the manufacture of widgets, and the PI team in White Memorial's ED has experienced some typical setbacks. In December 1999, for example, an outbreak of flu saw the number of ED patients jump from 94 a day to 168. Not surprisingly, turnaround times suffered. But aside from these kinds of situations, the ED has scored impressive gains in the delivery of emergency health care services and should go a long way toward attracting new patients and physicians. The ED's improvement efforts dovetail with White Memorial's overall business objective to refocus on customers. "We're in the process of setting new customer service standards and looking for new opportunities," says Nancy McDonough. Taking advantage of these opportunities will help make White Memorial the provider of choice for East Los Angeles.