quality improvement paper

Running head: QUALITY IMPROVEMENT PROJECT: EMERGENCY ROOM WAIT TIMES

1

Quality Improvement Project: Emergency Room Wait Times

John DeAngelis, Ellen Huff and Lowell Smith

Northern Arizona University

Health Care Systems

NUR 676

Dr Enid Rossi

October 12, 2014

Abstract

Emergency department (ED) wait times are an important facet of today’s healthcare.

Multiple studies have shown that extended wait times lead to decreased patient safety and

satisfaction. Medicare reimbursement is now tied to both patient satisfaction scores and wait

times. Hospitals are working to find creative ways to deal with the dual challenges of decreasing

the amount of time patients wait in the ED and increasing their sense of satisfaction after a

hospital visit. This paper aims to explore the current state of ED wait times, how it is a problem,

who is involved in the problem of long waiting times, and what can be done to decrease the

amount of time a patient spends waiting for care. It evaluates the current state of ED wait times

compared to ideal wait times and the reasons for any differences. This paper then explores the

use of a Fast Track program to help improve ED wait times and, consequently, patient

satisfaction scores. It lays out a plan of implementation and evaluation of testing a Fast Track

program in the ED. The goal of this paper is to identify if possible a ‘best practice’ approach to

minimizing ED wait times and optimizing the patient’s experience while in the Emergency

Department.

Keywords: Emergency Department, wait times, patient satisfaction, reimbursement

QUALITY IMPROVEMENT PROJECT: EMERGENCY ROOM WAITS 3

Quality Improvement Project: Emergency Room Waits and Customer Satisfaction

“More and more patients-and their primary care providers are taking advantage of the

emergency department’s ability to offer a 24/7, one-stop shop for all their ailments” (Kutscher &

Selvam, 2013, para. 4). With this continuing increase in volume of ER visits across the nation,

Emergency Departments are struggling to find new ways to adapt and serve their rapidly

expanding customer base.

The Charter of This Team is the goal of improving patient service and therefore

satisfaction in regards to each members’ respective hospital Emergency Department, by

eliminating or reducing gaps of time where services are not being rendered, and by minimizing

frustration buildup in waiting customers.

The steering committee consists of NUR 676 Group 1 triad: John Deangelis, Ellen Huff,

and Lowell Smith. Through multiple group discussions, and regular contact on an online WIKI,

this team has agreed to pursue improvement of patient satisfaction in an Emergency Department

setting. Considerable research has been performed on this subject, and this committee will be

determining which of many organizational and stylistic options would be best suited to apply in

this group’s setting. Logistics, budget, policies, and cultural consideration will all be considered.

There will be several preassemblies of this committee for re-evaluation of the process and the

direction of the improvement project.

The Scope of the project will cover several possible alternatives: adjustments in training

to staff; adjustments in manpower quantitatively an/or qualitatively; re-evaluation of operative

ergonomics of the patient ‘flow’ through – and out – of the department. Other considerations

outside of these parameters will be considered as well when ideas are brought forth during

brainstorming, external contributions or ideas discovered during continued research. However,


the possibility of reviewing an in-house survey from employees and/or patients/customers would

be considered. Any proposals for major departmental changes because of this project will require

initial approval up the chain of command as appropriate, and will also require at approval of a

preliminary budget. Major changes could include such projects as: reconstruction of floor plan or

addition of square footage to the facility; addition of more diagnostic equipment to supporting

departments, such as radiology, laboratory, respiratory therapy, etc.

Importance of this project in regards to our customer base is multi-fold in positive

outcomes. Improved customer satisfaction demonstrated through higher survey scores could be

considered a poll reflecting the word-of-mouth reputation of the hospital. Actual-resultant

decreases in ER wait times will decrease several health risks, including those of patients who

decide to leave the ER before being seen by a Physician, which can equal 3% of ER visitors

(Welch & Savitz, 2012). The patients that wait excessively can be at risk, and the patients who

leave without proper exam could represent significant unknown risks as well. The importance of

making some sort of adjustments of patient ‘down time’ becomes quickly self-evident. This

committee hopes to fulfill a need for better patient perception of care, and better actual delivery

of care. The differences and similarities between these two equally important prospects are

foundational for a successful community hospital’s relationship with its respective community.

This steering committee has considerable hospital-direct experience counted in decades.

All three have served and worked in Emergency Departments at some time during their careers,

with two of the three presently actually assigned to ERs respectively, and the third being an

Intensive Care Unit Nurse. The background, qualifications, experience and motivation of this

steering committee should benefit this Quality Improvement Project by understanding patient


and family member needs and by being able to effectively communicate actions taken to improve

outcomes in each respective individual’s situation.

The considerable progressive movement regarding improvements with ER wait times and

other methods of improving patient satisfaction is the primary challenge. This steering

committee hopes to sift through the copious number of articles and studies to reduce this number

by factors previously mentioned. Once this collection of options has been initially screened, the

next brainstorming session will take place to reduce improvement options to between 3 and 6

possibilities. These ‘finalists’ will then go through a second stage screening process with the

committee. This process will include a check-off list, which is still presently in development.

The check-off list in question will have considerations of program application culpability, such

as budget, logistics and manpower feasibility. The committee will also distribute these finalist

studies and methods of improvement to front-line employees, supervisors, and community

spokespersons for additional subjective and objective feedback.

After an appropriate time allowing for feedback, the steering community will determine a

final decision. Once the specific program has been selected, this committee will write up an

implementation plan: the plan will be reviewed, revised and set for beta-test in a respective

department. If policies need to be designed, the committee will either write these in conference

with, or delegate their construction to the department supervisor whose staff will be

implementing the improvement plan. Staff nurses, the ER Nursing Supervisor, the committee,

and the Director of Nursing will review these draft policies for feedback and possible revisions.

Lastly, with room for change in direction, tools will be designed for evaluation of the

quantitative and qualitative indicators for improvement – either by this committee, or through


appropriate delegation. These tools will provide feedback on the effectiveness of the change

along with the quality of its implementation.

Who cares and what do they care about?

According to Lewis Goldfrank, director of emergency medicine at New York University-

Bellevue Hospital Center, “If it’s an emergency, minutes count” (Sadick, 2014, para. 4). It can be

argued that this applies to customer service as well as life-saving measures. Today’s society is

one of instant gratification (Stempniak, 2013, p.31) and long gone are the days where people

would accept hours’ long waits in the Emergency Department. Additionally, hospital

reimbursement has become tied to patient satisfaction, causing an unprecedented focus on

customer satisfaction in healthcare. Hospital administrators are working to address long wait

times throughout the hospital in an effort to address this “growing consumer mindedness”

(Stempniak, 2013, p. 31). “Patients are comparing service they receive at hospitals to their

experience at a restaurant or hotel,” states Stempniak (2013), “and leaders should be looking to

those service industries for inspiration” (p. 31). So who are the customers of an emergency

department? Patients and family members, physicians, hospital administration, and healthcare

regulating bodies are all considered to be ED customers.

Patients

According to Elmqvist, Fridlund, and Ekebergh (2011), the two most important factors

influencing patient satisfaction in an ED visit are waiting times and information (p. 2610). One

of the greatest points of confusion regarding wait times is the misunderstanding of emergency

triage procedures (Wilkin, Cohen, & Tannebaum, 2012, p. 164). Patients expect to be seen in

their order of arrival and are frustrated, even angry, when others with a more acute illness are

seen before them. Papa et al. (2008) suggest that “An explanation of what they can expect with


regard to care seems to be just as important, if not more so, to patients than information on actual

conditions and can help to alleviate anxiety” (p. 348).

Elmqvist et al. (2011) also point out that there is “a close connection between patient

satisfaction and vulnerability” (p. 2609). Once in the ED, patients place their trust in staff

members, depending on them to provide appropriate care in a timely manner. This is best

summed up by the statement by Elmqvist et al. (2011): “In exchange for a medical examination,

the patient pawns his/her bodily control and time control” (p. 2611). ED staff must constantly

work to minimize this vulnerability by providing information and reassurance at every step

through the visit. When this sharing of information and support does not occur, patients describe

their ED encounter “as being non-caring, where physical needs are more important than the

alleviation of suffering and than a deeper understanding of patients needs” (Elmqvist et al., 2011,

p. 2610). Elmqvist et al. (2011) encourage a change in ED organization and mentality, “where

the subjective lived body with its existential needs and feelings has the same priority in

emergency care as that of the biological body and the physiological threat to life” (p. 2615).

Another contributing factor to long wait times is confusion about emergencies vs. non-

emergencies. Even with clear definitions, patients are sometimes confused about the acuity of

their injury/illness (Wilkin et al., 2012). This leads them to assume everything is an emergency.

Wilkins et al., (2012), state that “educational campaigns should concentrate more on how to

evaluate symptoms and determine when different health problems are potentially life threatening

rather than on… emergency vs. non-emergency” (p. 163). This would help patients to identify if

they needed to go to a community clinic before choosing the ED.

Some patients choose the ‘one-stop-shopping’ of an ED over a community health clinic

that may not have the services the patient is in need of or “does not offer the best health care”


(Wilkins et al., 2012, p. 163, 164). Wilkins et al. (2012) found that many patients experience

poor customer service at community clinic. This perception of substandard service implies that

“one reason people choose EDs for non-emergencies is that they feel more comfortable waiting

for health care in the ED than a clinic where they feel unwelcomed by the staff”. Although

highly subjective, the confusion, convenience, or personal preference of going to the ED over a

community clinic contributes to the long wait times in the emergency department.

Family Members

Family members of patients in the ED place a high value on communication and

exchange of information (Meek & Torsello, 2006; Papa et al., 2008). “Going to an emergency

department is often an intimidating and confusing experience for patients and families because

they fear the unexpected” (Papa et al., 2008, p. 348). Elmqvist et al. (2011) point out “being as

the encounters with the ED staff are fragmented, the caring tasks are often left to the next of

kin…[who end up] playing an important role in providing emotional support for patients during

the ED visit” (p. 2614). Family members are more patient and willing to wait when they feel

informed and engaged in participating in the plan of care.

Emergency Department Staff

By improving ED wait times and increasing patient satisfaction, the morale of ED staff is

improved. “Crowded ED conditions result in increased ambulance offload times, increased time

to clinician review, prolonged patient wait times, reduced patient satisfaction, increased patient

complaints, decreased staff satisfaction and decreased physician productivity” (Shetty, Gunja,

Byth, & Vukasovic, 2012, p. 375).

Emergency department staff members are facing increased pressure from patients, their

families, and hospital administration and the greater healthcare community to speed up their


care, eliminate long waiting periods and provide best-in-practice care. For example, in the United

Kingdom (U.K.) until 2011, the main performance measures for EDs were time-based (Alonso,

2013). They had a four hour door to discharge time target. This meant that staff members faced

conflict between the need to provide quality care and the requirement to meet time constraints

(Alonso, 2013).

Despite these pressures, the art of nursing and speed of care do not have to be mutually

exclusive. In discussing the future of nursing and technological changes, Huston (2013) states,

“Nurses need to make sure that the human element is not lost in the race to expand technology.

The human connection is the art of nursing and nurses need to be actively involved in

determining how best to use technology to supplement, not eliminate, human resources”.

Patients that receive personalized, ‘human’ care from staff members tend to “perceive the care

they receive as being of higher quality than is perceived by less engaged patients” (American

Sentinel University, November 26, 2013, para. 3).

Finally, the ED nurse’s role as a patient advocate can increase patient satisfaction.

“Advocacy by definition is tailored to the individual patient – including his or her cultural

beliefs, fears, and past experiences. Advocacy also means, by definition, inviting patient input

and participation” (American Sentinel University, November 26, 2013, para. 7). Elmqvist et al.

(2011) state: “Increasing the nurses role as the patients’ advocate during the waiting between

[triage] and the encounter with the physician can give the patient a feeling of being respected”

(p. 2615).

Physicians

In the past, providers have been “vague about priority levels and expected wait times”

(Elmqvist et al., 2011, p. 2612). The lack of sophisticated technology, and traditional doctor-


patient roles both contributed to this ambiguity. With ongoing changes to technology, wait times

for things like lab results and diagnostic readings are markedly decreased. With the advent of the

Internet, Wi-Fi, and smartphones, people are no longer willing to wait for information. They

expect that their doctors will provide results as quickly as possible without a prolonged wait.

At the same time, healthcare is moving from a physician-focused model to a consumer-

based model. Doctors are no longer accorded respect and resources without question. Rob Klein

captures that change: “Physicians have to learn that my time is just as valuable as theirs. In days

past, consumers may have been willing to sit in a waiting room for 22 minutes to see a trusted

doctor, but now they’re walking out” (as cited in Stempniak, 2013, p. 32). Health care is moving

towards patient-centered, physician-guided care, where a team of medical and nursing personnel

works to meet the needs of each individual patient (American College of Physicians, 2006,

January 30).

Because of the pressure on physicians to ‘treat and street’ patients in a timely manner,

there is a concern that by reducing wait times, patient care and safety will be compromised. “It is

not clear that the quality of care received by patients actually improves, and it may even worsen”

(Four hour ED rule backfire, 2012, p. 38). The American College of Emergency Physicians

(2012) recognized this possible problem:

Others have noted the potential for providers to deliver lower quality or cursory

assessments in an attempt to shorten the wait time or meet a certain maximum wait time

guarantee, leading to a negative impact on patient care…Processes created to meet

maximum ambitious wait time guarantees may also necessitate more interruptions in

provider workflow and handoffs between providers, introducing additional patient safety

hazards (p. 3).


There is a balancing act between keeping wait times short and providing high quality,

comprehensive patient care. Physicians must join with the rest of the ED staff to actively move

patients through the points of care while keeping them informed of their progress.

“By moving patients quickly to patient care areas for evaluation, patients perceive that

the wait time is acceptable,” Welch and Savitz (2012) state, and “timeliness of care is among

the strongest correlates with patient satisfaction. The time it takes to see a physician (door-to-

physician time) has the best correlation of all” (p. 149). In essence, patients are more willing to

wait if they feel that they are making progress towards seeing the physician and finding out what

is wrong. By providing information to the patient regarding what diagnostics will be ordered and

anticipated wait times, the physician fosters a “sense of safety [and] a secure foundation…in the

encounter” (Elmqvist et al., 2011, p. 2613). A streamlined, efficient process in the ED can

improve patient outcomes and satisfaction. This in turn can increase physician job satisfaction by

decreasing negative feedback received from patients and administration.

Hospital Administration

With reimbursement measures focusing more and more on customer satisfaction and wait

times, hospitals must actively work at improving both. “Hospital executives who ignore wait

times can expect a dramatic reduction in reimbursement” (Stempniak, 2013, p. 31). Due to the

increased difficulty in obtaining reimbursement for services, hospital administrators are

challenged to keep costs to a minimum and increase patient encounters.

Emergency departments are usually a significant contributor to hospital revenue.

According to the New England Healthcare Institute (2010), “that 34 percent of total hospital

gross revenue for inpatient services came from patients admitted through the Emergency

Department. The ED also generates revenue for the hospital through ancillary testing” (p.5). An


increase in patient volume due to decreased wait times can positively impact revenue. Positive

patient experiences in the Emergency Department may also influence a patient’s decision to

return to the hospital for outpatient/elective services.

There are many different groups, or customers, in an Emergency Department. All have a

vested interest in decreasing wait times and length of stay. The next step is to explore what is

currently being done in the Emergency Department and how effective it is.

What are we doing well now and how well are we doing it?

In order to identify what we are currently doing well in the Emergency Department (ED)

we must first identify several factors. This Charter has already identified the key focus groups

within this text which include patients, family members, physicians, hospital administrators and

health care regulatory bodies (Stempniak, 2013). In addition, quality improvement measures

must be identified to include cost of the measures already initiated, which would include

implementation costs of the measure, re-evaluation costs, costs of delays, and revision costs

(Tague, 2005). We will begin this process by identifying key players via a top down flow chart,

and another identifying the overall quality of improvements. Finally we will display a

deployment flowchart that identifies who is involved within the process improvement measures

and how they are affected by each step within the process (Tague, 2005).


Figure 1. Key Players (Stempniak, 2013).

One measure that has been effective in decreasing wait times in the ED and increasing

patient satisfaction scores is the emergence and implementation of Fast Track systems (Amirault,

2012). With excessive overcrowding in the ED comes excessive wait times. Consequently,

excessive wait times increase the likelihood of patient deaths within the hospital by

approximately 5% (Amirault, 2012). Amirault states, “ED admissions have increased by 11%

between the years 2001 to 2006 while the building of ED facilities has increased only 4%”.

(Amirault, 2012, p. 1). While some measures to improve process include patient education; in an

Customers involved in quality of care delivery in

the Emergency Department

Patients

Family Members of the Patient

Hospital Senior Admistrators

Health Care Regulatory Bodies

State Board of Nursing CMS

Primary & Seconday Providers

Physician & Surgeons Physician Assistants & Nurse Practiotners


effort to help potential ED patients identify what is and what is not an emergency situation, these

type of measures can take significant time to teach and need to be continually reinforced within

the community. Fast Track programs can assist with reduction in ED wait times almost

immediately (Amirault, 2012). Fast track programs are aimed at providing care to individuals

who otherwise do not present with immediate life threatening illnesses or injury. Fast Track is

aimed at providing care to patients that have been triaged and whom fall into the triaged category

of Urgent Care (Cosidine, Kropman, Kelly, & Winter, 2008). Fast Tracks are typically staffed

by Midlevel Practitioners including Nurse Practitioners and Physicians Assistants often under the

supervision of a Licensed Physician. In addition, ED Fast Tracks can care for individuals with

acute non-life threatening illness with improved outcomes as opposed to outcomes associated

with excessive ED wait times which can significantly increase patient mortality (Haley, 2008).

In addition, health care services will soon be extended to another 30 million Americans via the

Affordable Care Act (Amirault, 2012). Therefore, overcrowding conditions are predicted to

become more severe ultimately increasing ED wait times going forward (Amirault, 2012).

Fast Track programs can be very effective at decreasing wait times within the ED since

the focus of midlevel practitioners is to treat injuries and illness including but not limited to

“minor burns, minor broken bones, non-decompensating viral colds or flu’s, insect and animal

bites, and superficial cuts and bruises” (Amirault, 2012, p. 1). This is manifested by the fact that

between 60 and 80 percent of all ED visits are comprised of illnesses and injuries that fall within

the previously mentioned categories (Amirault, 2012). As a result, it is simple to see how fast

track programs can provide an increased effectiveness in expediting the check-in to treatment

processes. Furthermore, the newer streamlined approach assists in decreasing the patients

overall wait and time to discharge.


A study shows that currently approximately 58% of all ED’s have a Fast Track program

in place (Cosidine, Kropman, Kelly, & Winter, 2008). Within this case study 1296 ED

admission were surveyed to assess for criteria that would qualify them for inclusion into the fast

track program. Of the 1296 cases 822 individuals qualified for inclusion into the case study

(Cosidine et al., 2008). The Fast Track study was set up in a pre-existing area within the ED

using currently employed or contracted Physicians and Midlevel staff members as Fast Track

service providers. Additionally, a similar number of ED admits were chosen as case studies

from patients treated in the Emergency room. Admission criteria into the study within both the

Fast Track group and the traditional Emergency Medicine group consisted of cases including but

not limited to “minor burns, minor broken bones, non-decompensating viral colds or flu’s, insect

and animal bites, and superficial cuts and bruises” as previously stated (Amirault, 2012, p. 1).

Study findings were remarkable with a stark degree of contrast regarding the Length of

Stay (LOS) between the two study groups. First the Fast Track study group had a significant

decrease in the median LOS from previously recorded studies. Fast track patients within this

study had a median LOS equaling 132 minutes. By contrast the study group that checked

themselves directly into the ED had a median LOS of 313.51 minutes (Cosidine et al., 2008).

Both categories included patients that did not require admission into the acute care hospital. Yet,

patients participating in the fast track study group had an equal chance of being discharged

within 60 minutes at a rate of 14% which was equal to the study group of traditional ED patients

(Cosidine et al., 2008). In addition, discharge rates were higher for Fast Track patients at the 2

hour mark. This was manifested by a Fast Track patient rate of discharge of 53% versus a 44%

discharge rate achieved by traditional ED patients within the same time frame (Cosidine et al.,

2008). Additionally, there was a significant degree of discrepancy for LOS between the 2 study


groups for patients that were admitted into the hospital. Fast track patients were admitted to the

hospital at a median rate of 116 minutes, whereas traditional ED patients were admitted at a rate

of 309 minutes (Cosidine et al., 2008).

The findings conclude that the Fast Track patients not requiring admission were

discharged at a rate of 181.51 minutes faster than the traditional ED patient’s not requiring

admission. In addition, Fast Track patients were admitted at a significantly faster rate than

traditional ED patients were admitted with a difference of 193 minutes. Although there were no

indications that Fast Track rates to discharge or admission were superior to traditional ED

patients at the 60 minute mark since both groups had a discharge rate of 14% (Cosidine et al.,

2008). Yet, upon further review the Fast Track program did not precipitate any significant

benefits to patients presenting to the ED with life threatening illnesses, since their admission rate

was consistent with the rates of admission within the control group for the same category

(Cosidine et al., 2008).

Therefore, the findings of this study conclude that the Fast Track program, which is

relatively new to the pre-hospital patient triage and assessment setting, would be an effective tool

to improve the quality of care within the emergent care environment since expeditious treatment,

admission and or discharge is provided at a rate that is approximately 50% faster than traditional

ED treatment for approximately 60% to 80% of the total ED patient population. It is safe to say

that the decrease in treatment times is highly likely to improve patient satisfaction scores,

increase productivity, decrease the overall cost of care and ultimately improve the quality of care

delivered going forward. In addition, with only 58% of all ED’s providing Fast Track services it

is possible to see that this service could potentially fill the void for most delayed and or deferred

services secondary to overcrowding. This would be possible if the additional 42% of all ED’s


implemented Fast Track programs within their ED’s. Furthermore, this can be precipitated

without the implementation or expense of building new ED’s since most facilities already have

the space required to launch an effective Fast Track Program.

Figure 2. Emergency Versus Fast Track (Tague, 2005).

The average costs of a build out for a Fast Track program can potentially reach or even

exceed 1.8 million dollars (Shushereba, 2010). Yet, Fast Track Programs have the potential to

decrease LOS for patients that meet criteria for Fast Tracking. This can be an effective way to

decrease productivity costs by decreasing the amount of time needed to either discharge or admit

the patient to the acute care setting by at 50%. “The total number of ED visits increased 10%

from 1,586,179 in 2006 to 1,760,527 in 2012” (Legislative Program Review and Investigations

Committee Connecticut General Assembly, 2013, p. 6). With the implementation of the

Affordable Care Act in 2014 it is projected that an additional 30 million individuals that are

otherwise not entitled to services will be eligible for health care insurance under the tenants of

Emergent Injury or

Ilness Care

Discharge Rate @ 2h 53%Increased ProductivityIncreased Quality of Care

Acute Care Admissin rate 116minIncreased Patient SatisfactionIncreased Quality of Care

Discharge Rate 2h 44%5% Increase in Mortality RatesDecreased Productivity

Acute Care Admission Rate 309minDecreased Patient Satisfaction ScoresDecreased Productivity


this act (Amirault, 2012). With this monumental increase in the number of insured within the

United States (US) there will be an exponential increase in the amount of individuals seeking

emergency care in the future. With the implementation of Fast Track programs within the ED it

is possible to streamline patient care activities allowing care providers to increase the amount of

care delivered by 30% to 40%. At a build out cost of approximately 1.8 million dollars for a Fast

Track program it becomes apparent that this is the single most effective way to save time and

money in an effort to meet the looming demands that will be made on the ED’s in the immediate

future (Cosidine et al., 2008). Costs for building an new ED facility can easily exceed 10 to 20

million dollars which is significantly higher than the cost to improve and build out pre-existing

structures in an effort to create a new Fast Track program within pre-existing walls (Stank,

2014). As stated previously, beneficiaries of a new fast Track program include but are not

limited to senior hospital administrators, physicians, patients, patient families and regulatory

agencies (Stempniak, 2013).


Figure 3. Deployment Flow Chart (Tague, 2005).

Patients

Shorter Wait Times

LOS ≤ 132 min

Increased Patient Satisfaction Score

5% Decrease in Mortality

Family Members

Decrease in Anxiety

Increased Patient Family

Satisfaction

Physicians & Midlevels

Better Outcomes

Inceased Revenue

Secondary to Increase in

Patient Satisfaction

Scores

Decrease in Liability

Secondary to Decrease in

Mortality rate

Senior Administrator

s

Increase in Productivity

Increased Revenue by

Seeing 30-40% More Patients

Increased Revenue by

Inceasng Patient Satisfaction

Scores & Reimbursement

Payout

Decrease in Liability

Secondary to Decrease in

MOrtality Rates

Regulatory Agencies

Shorter Surveys

Fewer Patients Complaints

Decrease in Operational Costs

Secondary to Fewer Patient

Complaints

Improved Public Opinion Ratings

Secondary to Decreased Statewide

Mortality Rates


Quality Improvement Process

Preferred state of care in the ED

In many cases care delivered within the ED can take as long as 5 to 6 hours in order to be

either discharged or admitted (Cosidine, Kropman, Kelly, & Winter, 2008). Exacerbating issues

include increased patient to physician times in which the patient may not be seen by a physician

for extended periods equal or greater than 1 to as many as 2 hours (Cosidine et al., 2008). These

extended periods of time erode patient, family and care provider relationships, trust and

ultimately decrease the level of patient satisfaction. It is the goal of this Charter to identify

process’s that will lead to a significant increase in patient satisfaction by decreasing door to

physician times to 10 to 20 minutes maximum and implementing process’s that have been

proven via evidence based practice studies that will assist in streamlining patient care and

decreasing LOS within the ED to equal or less than 130 minutes maximum. By achieving these

goals we hope to additionally decrease productivity costs and increase ED revenue by as much as

20 to 30% percent over time. This can be achieved by Fast Tracking the 60 to 80% of patients

that fall into a Triage level of 4-5 (Amirault, 2012).

Gaps between current and preferred state

Access to health care in recent years has become more elusive with the revision of

Medicaid within many States. Medicaid increased requirements for individuals to become

enrolled in in the State of Arizona. This change precipitated the disenrollment of approximately

250,000 individuals that were previously enrolled in the Arizona Health Care Cost Containment

System (AHCCCS) (Pitzl, 2011). Many of the individuals displaced from AHCCCS are afflicted

with chronic illnesses which forced them to participate in the plan in the first place. Because of

this fact this issue has become more of a crisis for the ED’s currently operating in Arizona today.


In addition, because the majority of the individuals that were un-enrolled from AHCCCS are

middle aged and or elderly with many having chronic illnesses, there is an increase in the

likelihood that these individuals will have to seek treatment within the Arizona health care

delivery system for acute on chronic exacerbations.

Now that these individuals do not have insurance that would qualify them to receive

treatment at a clinic or participating Urgent Care facility, they will seek care within the ED’s

currently operating in the State of Arizona (Pitzl, 2011). In addition, patients these patients will

delay care because of their lack of insurance and lack of ability to pay. Yet, when they do present

to the ED they will surely be sicker requiring significantly more expensive treatments and

diagnostic testing. Furthermore, these individuals will not be able to pay since they do not have

AHCCCS insurance and most fall before the poverty line. This creates a scenario where ED’s

and hospitals will not be able to be reimbursed for the services that they provided to this patient

population. Yet, the tax payer will continue to absorb this cost since taxes will not be generated

or paid on the significant amount of uncollectable debt that will accumulate for all ED’s and

acute care health facilities (Pitzl, 2011). In addition, ED length of stay (LOS) will certainly be

impacted negatively by the inevitable increase in ED visits by this patient population, requiring a

much higher level of care (Debt.org, 2014). While addressing issues such and AHCCCS

unenrollment it becomes apparent that multiple process improvement measures must be applied

in an effort to improve the overall quality of care delivered here in Arizona by decreasing LOS

and patient to physician times.

Process improvement measures

ED overcrowding is like many other problems in the sense that there is no single magic

bullet that will solve the problem independently. Many hospitals have significant waiting times


often exceeding 5.5 hours that lead to an average walk out rate of approximately 2.3 to 5 percent

annually (Patel & Venson, 2005). The most prominent reason for patients to go Against Medical

Advice (AMA) in the ED is the extensive length of time it took for them to see the physician

(Wykes, 2013). Patients and families often feel neglected and become disenchanted when

waiting to see the emergency care provider. These feelings of neglect often give rise to feelings

of frustration and helplessness. These feelings of helplessness can precipitate a cascade of

emotions and behaviors including but not limited to developing feelings of mistrust toward care

providers, increased anxiety, hopelessness and even anger. Any of these emotions can progress

to a level where the patient feels that their only choice is to leave AMA. By leaving AMA a

patient may be putting themselves at risk for a progression of their current illness or injury

leading to potential decompensation and even death (Patel & Venson, 2005).

Although the patient may have made the choice to leave AMA on their own accord it is

the responsibility of the care providers to do everything possible to precipitate an expeditious

patient physician interaction and communicate any delays effectively in order to allay any

building feelings of anxiety, helplessness, mistrust, hopelessness and anger (Patel & Venson,

2005). As discussed in previous paragraphs Fast Track programs have significantly impacted

patient to physician wait times by decreasing the average ED LOS by as much as 50% in most

cases (Cosidine, Kropman, Kelly, & Winter, 2008). By giving a patient a number indicating how

quickly their patient needs to been seen, based on the acuity of their illness the care staff are able

to triage patients more effectively (Combs, 2012). Patients presenting with a triage number of 1

indicate an immediate need for definitive treatment in order to be stabilized expeditiously (Slovis

& Jones, 2014). Whereas, patients presenting with a triage number of 5, with a condition such as

a cold or flu virus and is otherwise stable and lacks impairment of any kind, other than


discomfort are considered non-emergent. Those patients presenting with a triage number of 1-3

will be checked into the ED while patients presenting with triage numbers of 4-5 are more

appropriately admitted to the Fast Track program (Combs, 2012).

While Fast Track can be highly effective with decreasing LOS by approximately 50% for

triaged patients with a score of 4 and 5 this method does not effectively decrease the door to

physician time for that same patient. Therefore, this method alone will be much less effective if

implemented as a single process for improvement. Several hospitals have introduced additional

measure for process improvement such as Team Triage. Team Triage assists in significantly

improving patient to physician times. A triage team is often composed of an Emergency Room

Physician, an ED Registered Nurse and a Paramedic (Wykes, 2013). The focus is to allow the

Physician and Nurse to assess the patient within 10 to 20 minutes of arrival into the ED waiting

room (Wykes, 2013). This helps the ED staff to expeditiously identify cases presenting with

triage numbers of 1 and 2 in an effort to bring them back into a bay to initiate definitive

treatment (Slovis & Jones, 2014). Patients presenting with triage numbers of 3 are given

increased priority over patients presenting with triage numbers of 4 and 5 and are brought back

to the ED bay as soon as one becomes available (Slovis & Jones, 2014). Patients presenting with

triage numbers 4 and 5 may be discharged immediately or may be required to return to the

waiting room pending lab results and diagnostics that were drawn or provided while the patient

was in attendance at their initial interview with the Physician and Team Triage (Slovis & Jones,

2014). While the process improvement measure Team Triage is effective at increasing door to

physician times by as much as 50 to 110 minutes it is also effective at assisting in decreasing

LOS within 60 to 80 percent of the ED patient population by quickly identifying patients that


present with a triage score of 4-5. This allows these individuals to be placed on the Fast Track in

a more expeditious manner (Slovis & Jones, 2014).

Further process improvement measures to be taken include patient education regarding

what constitutes an emergent health care issue and what does not. This type of education is often

performed by Team Triage when patients are identified as belonging to category 4 and especially

5 since 5’s do not require immediate emergent care (Wykes, 2013). According to Wykes (2013)

approximately 40% of all ED visitors were ill enough to warrant admission through the ED.

This leads us to the conclusion that at least 60% of all ED visits do not require hospitalization

after triage and assessment in the ED. Therefore, 60 % of the total ED population will directly

benefit from education regarding the identification of illness’s that are emergent in nature and

require a visit to the ED. Education should include alternative resources for assessment and

treatment of sub-acute illness and injuries. This would include clinics and Urgent Care facilities,

which can provide a higher level of care than clinics at a significant savings to the patient and

their insurance provider. Rates of savings can be as much as 66 to 75 % depending of the

diagnostic test and treatment being provided (Debt.org, 2014).

Finally, the implantation of team assignments can additionally decrease LOS while

improving the overall quality of care. Teams consist of one physician, two nurses and 1

technician (Patel & Venson, 2005). The premise is that patient care is delivered in a more

continuous manner that expedites care since more than one individual is responsible for each

patient. This precipitates an expeditious performance of diagnostic measures and treatments

since there are more individuals assessing the chart for new orders and additional hands to

perform tasks a higher rate of completion (Patel & Venson, 2005). Studies show that team

assignments increase overall production by as much as 15% by reducing time to physician from


70 minutes to 60 minutes (Patel & Venson, 2005). The percentage of patients seen by physicians

within the first hour increased significantly by 12% from a rate of 56.3% to 64% (Patel &

Venson, 2005). “The number of patients seen by physicians taking greater than 3 hours

decreased by 33% from a rate of 17.8% to 11.8% (Patel & Venson, 2005), while the rate of

AMA discharges decreased by approximately 30% from 2.3% to 1.6% (Patel & Venson, 2005).

In conclusion patient to physician rates were highly affected by decreasing previous time

frames from 1 to 2 hours to 10 to 20 minutes with the implementation of the process

improvement measure Team Triage (Slovis & Jones, 2014). This indicates a process

improvement of 83% overall which is a significantly higher rate of improvement than this

Charter initially expected to see. While the Team Triage measure had the most significant rate

of improvement Fast Track was not far behind in its effectiveness at decreasing LOS. After the

implantation of Fast Track for triaged patients receiving a score of 4 or 5 LOS decreased from

313.51 minutes to a LOS of 132 minutes for discharged patients (Cosidine et al., 2008). This too

is a significantly higher rate of improvement than this Charter expected at a measured rate of

58%. In addition, patients requiring hospitalization had improved LOS from 309 minutes to 116

minutes (Cosidine et al., 2008). This indicates an LOS improvement rate of 42.5% from

previous process’s.

Additional process improvement measures include Team Assignments which could

potentially decrease LOS another 10 minutes overall (Patel & Venson, 2005). Furthermore, this

process improvement measure can increase the rate of patient to physician contact by 8% (Patel

& Venson, 2005). With the implementation of Education for ED clients regarding what

constitutes admission criteria to the ED it is apparent that these process improvement

interventions could significantly impact LOS and patient to physician time frames in a positive


manner. In addition, with only 58% of all ED’s participating in Fast Track programs this process

improvement measure can significantly improve the prognosis of ED crowding in the immediate

future. This is especially important since 30 million Americans will become insured potentially

requiring ED services going forward.

By implementing Fast Track programs within the other 42% of non-participating

hospitals it is apparent the we will require the building of fewer new ED’s since this measure

will be able to increase the delivery of care within the ED by approximately 30 to 40% going

forward. Additional benefits to this measure will be increased savings since Fast Track Build out

expenses typically cost less at an average of 1.8 million dollars as opposed to a minimum

investment of 10 million dollars required to building a brand new ED (Stank, 2014). Fast Track,

Team Triage, Team Assignments and direct patient education by care providers regarding how to

avoid ED visits and what constitutes criteria for an ED visit are each effective individually. Yet,

when applied together in a single process improvement plan it becomes apparent that the

cumulative effect of all four processes can precipitate a significant level of relief on our already

overcrowded and strained ED system.

Root cause

The consistent purpose for this retrofitting and reengineering of the Emergency

Department flow and efficiency is due to the act of responding to a continuing increase in

Emergency Room visits. More Emergency Departments are being forced to adapt to an increase

of patient volumes, many of whom are at a triage level 4 or 5 and could receive treatment

elsewhere, perhaps even with less wait time. The customer demographic of those who attend the

Emergency Department for service has been changing. “Dwindling compensation and rising ED


closures dictate that meeting this challenge demands greater operational efficiency ” (Hurwitz, et.

Al, 2014, para. 1).

This team’s members each performed their own research through Cline Library,

Medscape, Up-to-Date, and other primarily internet-based peer-reviewed resources. Then we

collaborated through electronic group communication – sometimes on telephone, but mostly

using text messaging, so as to be able to remain in communication even away from computers.

With this team in constant discussion, an agreement and consensus on opinion was formed:

while demographic trends were changing in the form of increased Emergency room visits - low-

acuity and otherwise – the majority of hospitals were too slow or even resistant in paying

attention to these changing trends. This lack of foresight preparatory organization has caused the

vast majority of hospitals and their respective emergency rooms to essentially be caught off-

guard in regards to their increase in patient flow and customer satisfaction operative models.

Had the respective leaderships performed their duties on a more evidence-based research

principle, they would have noticed the changing trends, which have been apparent for many

years. The choice of not acting in preparation, and instead operating in a mode of ‘catch-up’, or

‘crisis management’, has led to the situation hospitals are in now. It is apparent to this team

through our respective and collective professional experience that a good portion of this

logistical crisis could have been easily averted.

One portion of the trend that preceded the logistical crisis is the definite increase in

patients who use the Emergency Department as their primary care, instead of attending an actual

clinic. Customers/patients reported many reasons for this change. One primary change in visit

trends is due to actions in response to the following (Nelson, 2011):


pain, which is/was desired to be addressed as quickly as possible regardless of

acuity,

either a worsening of, or a continued (read - unimproved) level of, their condition

of illness, or

a complaint or issue that affected their activities of daily living.

An example of illness complaint that could fit any or all of the above categories, and yet remain

a probable acuity level of 4 or 5, would be a toothache. Considerable pain is typically involved,

the condition never improves on its own, and often a patient would not be able to chew food

without increasing discomfort. The drawback of an Emergency Room visit for a patient like this

is that virtually no ER has a dentist on their staff, and the patient will be treated for pain

management, and will also be given instructions to continue care with their dentist. Once the

crisis (pain) is averted, some patients neglect to follow-up as instructed, eventually repeating the

cycle. In addition, adult patients relying on AHCCCS for insurance do not receive any coverage

for dental needs. This further limits the patient’s ability to follow up as directed and increases the

likelihood of complications. This same trend can be observed with other illnesses as well, with

similar predictable results.

Patients additionally had issues with their effective involvement in their own health care

system. Sometimes patients use the Emergency Department because they simply don’t have a

Primary Care Physician of their own. Sometimes these patients have fallen into the inappropriate

habit of using the ER instead of their PCP because: 1) an appointment isn’t necessary and they

can just walk in to be examined (even without health insurance); 2) they cannot obtain an

acceptable appointment date/time with their PCP due to overbooking, or; 3) they are


experiencing their illness/chief complaint in a time window when their normal PCP is not open

of available (Carret, Fassa, & Kawachi, 2007).

Another precipitating cause the group discussed was the typical lack of knowledge of

current practices, in this case, Emergency Department patient flow. The group agrees that the

term ‘lack of knowledge’ isn’t fully accurate; the knowledge is out there in great volumes. The

term could represent the choice not to acquire new knowledge. While many new models have

been researched for years, their degrees of improvement have often remained overlooked by

facilities and corporations choosing to remain incumbent in their mode of operation. The old

saying goes: ‘if it ain’t broke, don’t fix it’. But the Emergency Room patient management

systems are, by way of entropy, ‘broke’. So now as each leadership group decides it is time to

review the research, and test out a model that would work best in their own particular situation,

the problems that could have been avoided are now deeply entrenched. Instead of progressively

staying ahead in terms of the evolution of care, they are in a constant state of catch-up.

Once the service unit, for lack of a better choice of terms, decides on a new operative

model, the next step is to begin the indoctrination process of the staff into completely integrating

the system into their everyday function. This act can include the redefinition of many employees’

job descriptions; it can also very likely include a great deal of facility policy re-writing in regards

to the new model and its standards of performance.

Fortunately, one of the elements regarding manpower is one that is quickly fading into

the past. That is the application of the mid-level practitioner. This flexible position fills many

possible needs that are as of yet still in the process of being defined. The good news is that the

stigma that some providers have carried toward mid-levels is fading as the usefulness is

becoming more and more self-evident.


Another element to the implementation of these service upgrades is in the improvements

made to the facility itself, which can mean re-engineering a great deal of infrastructure just to

modify existing floor plans. The consideration of additional square footage takes up even more

effort.

With all of these factors acting as a barrier to what should be a continuum of developing

progress in health care, one can see why it is much easier to turn a blind eye in regards to

keeping up with latest health care developments. Now take into consideration the operating

standard of any Emergency Department – it runs 24 hours a day, 7 days a week, 365 days a year

– it is easy to see why hampering a department with the shifting of so many core paradigms

could be intimidating. Nonetheless, there comes a point where this neglect reaches critical mass,

and the changes must be addressed. In the case of this group’s facility, it came in the form of

progressively growing complaints of worsening wait times, and overall poor grades for customer

service.

The other area in Emergency Room treatment that has been frequently ignored is the

focus on levels of customer satisfaction. Customarily, the emotional needs of the patient have

taken the lowest priority in Emergency Services. Considering the original functionality of

Emergency Services, this makes sense. The Emergency Department staff is on hand and trained

for many life-threatening issues, all which take precedence over the frustration of a family

member sitting out in the waiting room. To put it more cynically, there has been no way to bill

for emotional support. However with a rise in patient options, such as a stand-alone Emergency

Room or Acute Care Clinic, the climate has become a buyer’s market of sorts. With this prod in

competition for the patient dollar, more attention has been focused on addressing the emotional

comfort level of patients and the family members who often attend the visit alongside them.


To reiterate, this group believes the root causes comes in the form of an organization that,

for whatever group of reasons, is resistant to change. What is the root cause of this resistance can

be speculated by many, and perhaps they could all be somewhat right with their speculation:

greed, fear, ignorance, complacency, finance, etc. There’s no end to the motivation or lack

thereof in regards to why organizational structures do not keep up with the times. So this group

chooses to remain thankful that this particular facility has finally chosen to take the leap forward.

Solutions for root cause

Often times circumstances in health care, change without much knowledge as to what is

changing and how changes to the demographics are occurring. This is because changes in

demographics are often insidious within a geographical area (Cygan, 2010). In addition,

responses to change can cost a significant percentage of an emergency department’s annual

budget (Hurwitz et al., 2014). Therefore, administrators can become complacent and apathetic

secondary to the changes that they are facing especially since costs can become excessive when

addressing such changes (Carret, Fassa, & Kawachi, 2007). As a consequence changes in

demographics and attempts to keep up with these changes are driven by monetary incentive or a

lack of incentives to deal with these changes, which can make the emergency department

ineffective over time. The implementation of fast track programs, team triage, team assignments

and education programs; designed to educate patients regarding what is an appropriate

emergency department issue, have significant costs tied to them (Stank, 2014). Therefore,

administrators must have an incentive to invest in programs that will assist with reducing wait

times and against medical advice self-discharges in the emergency department (Hurwitz et al.,

2014).


The Hospital Customer Assessment of Health Care Providers and Systems (HCAHPS)

survey has provided the incentive for health care providers and health care systems to improve

their customer service methods which include reducing wait times within the emergency

department (HCAHPS, 2014). By tying compensation to customer satisfaction the Centers for

Medicare and Medicaid Services (CMS) has effectively reduced the level of apathy by promising

that lower scores will be compensated with lower payouts (HCAHPS, 2014). With the promise

of reduced payouts in an industry that already has difficulties capturing adequate revenue to

offset costs, administrators can only face the facts of adaptation or the demise of their

organization and their future within that organization. In addition, administrators that have failed

once within one health care organization will be sure to have difficulty finding another health

care organization willing to take a gamble on them going forward since they have already failed

their previous organization (Hays, 2008). Organizations must identify the customers that they

serve within their organization. In health care this includes but is not limited to patients,

employees, families, physicians, midlevel’s, other senior administrators and regulatory agencies

(Stempniak, 2013). Therefore, it is important for an organization to identify the issues that are

currently preventing or may prevent good HCAHPS scores in the future.

There are twenty seven questions that are asked after the patient has been discharged

from the facility that they were treated in. Eighteen of these questions are core questions

regarding critical aspects of a patients hospital experience including communication with nurses

and doctors, the responsiveness of hospital staff, the cleanliness and quietness of the hospital

environment, pain management, communication about medicines, discharge information, the

overall rating of hospital, and if they recommend this hospital to others in the future

("HCAHPS," 2014). It is easy to see how most if not all of these eighteen questions can pertain


directly to a patients stay within the emergency department. In addition, first impressions are

often the ones that stick with a customer. This makes the emergency department the primary

department required for creating a good impression for the hospitals clientele (HCAHPS, 2014).

By utilizing a modified fault tree a visual illustration can be made in an effort to identify

the resulting outcomes of poor customer services in the emergency department as opposed to

similar incidences in the inpatient units:

As illustrated in the previous graph patient satisfactions scores are easier to improve once a

patient has been admitted since the physician to patient time has been addressed and issues such

Delay in physician patient interaction

In the emergency department

Bad first impression of facility

Poor patient satisfactions scores on HCAHPS

Less likelihood to improve outlook of patient for

facility

Longer wait times before treatment

Increase in anxiety and symptomology such as pain

and discomfort

In an in-patient unit

Patient has already seen a physician and has a room

placement

Pain issues have already been addressed

Higher patient satisfactions scores on HCAHPS

There are more care providers including Patient Care Techs, Dieticians, and

Therapists etc. to assist with patient care


as pain, comfort and privacy have been provided for (Hays, 2008). While attempting to provide

for these shortcomings, administrators concerned with dwindling compensation can take

measures to improve this bleak outlook created over the last twenty years. This poor outlook was

created from a lack of investment in management leadership infrastructure and the practical

infrastructure of the physical facility itself (Hays, 2008).

In an effort to progress beyond the crisis of dwindling compensation as a result of poor

patient satisfactions scores, administrators must invest in creating an effective leadership team

focused on developing a new and more responsive management leadership infrastructure (Hays,

2008). Management Leadership Coaching is effective at creating an atmosphere of lifelong

learning and accountability. Leadership Coaches are managers that work with customers on an

individualized basis and assist them in developing goals and creating a plan to achieve these

goals (Hays, 2008). In this case their customers include but are not limited to nurses, therapists,

technicians, physicians, patient care techs, patients and their families. Their approach is tailored

to meet the needs of each individual customer in an effort to optimize the outcome of the goals

and plans identified. Coaches encourage a process of discovery by listening, observing, and

preparing their plans to fit each individual’s needs (Hays, 2008). One approach is to assist in

improving the quality of under achieving employees and process’s within an organization in an

effort to improve employee retention (Hays, 2008). Often by improving antiquated processes the

Leadership Coach can improve the performance of the underachieving employee (Hays, 2008).

Leadership Coaches can also improve the quality of achievement within an organization

and its employees by instilling a culture of continued and ongoing education and learning (Hays,

2008). The value in continued education and learning will help employees to become more

accepting of the inevitable changes that will continue to metamorphosize the environment in


which they work. Dwindling payouts can and have been a significant incentive for change in an

effort to treat patients and families with the highest regard as customers. Leadership Coaches

achieved this by listening to and observing the patients and their families’ relative the concerns

that they had over the past twenty years prior to the implementation of the HCAHPS scoring

system.

One of the primary concerns was increased wait times in the emergency department

waiting room that often reached an average of three and a half hours prior to the implementation

of process’s that inevitably decreased the overall wait to less than half of the previous time. This

included the implementation of the Fast Track program that attempted to triage lower acuity

patients of triage levels 1 – 3 so that they could receive treatment almost immediately during

their triage assessment (Cosidine et al., 2008). Patients with a triage number of 1 and 2 could

often wait in the emergency waiting room for their diagnostic radiological and lab results in an

effort to free up space for higher acuity patients. Leadership Coaches continued to identify other

issues concerning their patients that included long waits to see a physician face to face. After

listening to staff the concept of team triage was developed. Team triage is designed to promote

physician to patient meetings upon assessment in the triage bay. The team consisting of a patient

care tech, a Registered Nurse and a Physician assess the patient upon admittance into the triage

bay. Labs are sent at this time and the patient is taken directly to radiology if diagnostic imaging

is required. Those with a triage level of 1 and 2 are settled back into the emergency department

waiting room pending results. Those with scores of 3 or higher are fast tracked into an ED bay as

soon as possible (Slovis & Jones, 2014). In addition, Leadership Coaching has been effective at

developing additional team approaches that include Team Assignments. These Assignments

consist of two Registered Nurses, one patient care tech and one physician (Patel & Venson,


2005). This approach was developed in an effort to reduce lags and lapses in care for emergency

department patients prior to admission or discharge (Patel & Venson, 2005). This plan was

developed after listening to patients and families and then consulting health care providers

regarding their ideas on how to improve patient satisfaction in this area.

Plan for a Test of Proposed Solution

This Charter has discussed many barriers and possible solutions to the problem of

increased wait times and lengths of stay in the Emergency Room. Our proposed solution is to

create a Fast Track section of the Emergency Room using existing staff and facilities. Due to the

high cost of creating an area specifically dedicated to Fast Track, we will limit our test to using

what is already at hand and, if successful, we will then work towards creating a dedicated Fast

Track area within the Emergency Room.

The Fast Track area will be staffed by a mid-level provider, an RN, and a patient care

technician (PCT) or paramedic. Operating hours are to be 1000-0000 which are normally the

peak patient presentation times in the ER. The area of the ER to be used will be the

Disposition/Procedure (DP) room, consisting of six reclining chairs and one computer station.

The study will run for two months with weekly assessments of progress using the Plan-Do-

Study-Act cycle to facilitate evaluation (See Figure 4).


Figure 4. Plan-Do-Study-Act Cycle (Tague, 2005).

The goals of this test must be beneficial to the process of ER patient flow and reflect our

efforts to improve patient care and overall satisfaction. The goals of this proposed test are:

1. To decrease door-to-provider times to less than 20 minutes,

2. To decrease door-to-discharge time to less than 130 minutes, and

3. To increase patient satisfaction scores from the current level of 81% to 90%.

Discharge goals were set based on research done by Cosidine et al. (2008) showing improved

patient outcomes and satisfaction. Follow-up calls have been proven to show “significantly

increased patient satisfaction, compliance with medication instructions, and the perception of

health improvement” (Cochran, Blair, Wissinger, & Nuss, 2012). These phone calls can be

performed by clinical staff including nurses and PCTs.

We will be focusing on a specific patient group including those who qualify as an

Emergency Severity Index (ESI) triage score of 4-5 (Agency for Healthcare Research and

Quality (AHRQ), 2012). The ESI is “triage algorithm that provides clinically relevant


stratification of patients into five groups from least to most urgent based on patient acuity and

resource needs” (AHRQ, 2012) with one being patients whose lives are in imminent danger.

Patients with an ESI of 4-5 include “minor burns, minor broken bones, non-decompensating viral

colds or flu’s, insect and animal bites, and superficial cuts and bruises” (Amirault, 2012). We

would add sciatica and dental issues to this group as well.

Figure 5. Ideal Treatment Cycle Time (Tague, 2005).

The implementation of this test would be relatively easy in regards to the physical

facility. The DP room already exists for Fast Track patients but is under-utilized by staff. The ER

staffs for a dedicated DP nurse but that person is usually used to float around the department to

assist other nurses instead of opening the DP room. Prior to implementation, the ER nursing

staff, especially the charge nurses, need education regarding the use of a Fast Track program and

the benefits of using the DP room specifically for Fast Track patients.

The largest foreseeable challenge to implementing this program is dedicating one mid-

level provider solely to the Fast Track program. Currently, our facility uses two physicians and

two PA/NPs to cover the entire ER. Taking one away may cause anxiety and stress among the


ER providers. The ER providers also require some education regarding the benefits of using a

Fast Track program. However, we are confident that as the Fast Track program proves to be

useful and helpful in lowering the number of patients that are seen in the main ER, these

anxieties will be alleviated. Cosidine et al. (2008) caution “Failure to staff fast-track areas with

appropriate medical staff results in the cessation of, or interruptions to, fast-track programmes

[sic] and interruptions occur more frequently when medical staff were expected to work between

fast-track and other ED treatment areas”. Having the support of the ER providers is essential for

this program to succeed.

There are three decision points for the continuity of patient care in the Fast Track

program. First, are they an ESI level 4 or 5? This determines if placement into the Fast Track

section of the ER is appropriate. Second, do any diagnostics need to be ordered? This further

differentiates between an ESI level 4 or 5 and gives the team an idea of how short the patient’s

visit in the ER should be. And third, after receiving the results of the diagnostic tests, is the

patient’s condition stable or are they going to require further resources? If they are going to need

further diagnostics or if their condition is more serious than initially presented, the patient may

be removed from the Fast Track program and placed in the main ER for further care (See figure

6).


Figure 6. Detailed Flowchart of Fast Track Process (Tague, 2005).

Patient arrives

Discharge

Provider/Charge nurse notified

Diagnosis made

Procedures completed as

needed

Review discharge instructions

Triage per protocol

Evaluate results

Diagnostics performed

Seen by provider

Triage performed

Pt. taken to Fast Track room

Hand off triage to Fast Track team

Pt. signs in

Triage notified of patient

Is pt. ESI of 4-5?

Do tests need to be ordered?

Is patient condition stable?

Patient to waiting room

Place in ER room

Wait for results


Data points will be collected including door-to-triage, door-to-provider, and door-to-

discharge times and customer satisfaction feedback. Data will be collected using a table as

follows:

Date Pt. visitnumber

ESI level

Door-to-triage time

Door-to-provider time

Door-to-dischargetime

Date offollow up

Form completed?

Positivepatient satisfaction?

Need further follow up?

10/31/14

(Example)

99999 4 5 17 118 11/2/14 Y Y N

Standardization Plan

At the conclusion of the study, all of the data will be evaluated to determine if the Charter

has met its goals. This will show whether the Fast Track program is an asset to the Emergency

Department and is fiscally and physically worth implementing. Data will be analyzed on a

weekly basis and correlated with data from the same time period in the previous year. Line

graphs will be used to show trends and bar graphs will be used for comparison between years.

Figure 7. Example of Weekly Average Wait Times Line Graph (Tague, 2005).

1 2 3 4 5 6 7 8 9 10 11 120

20

40

60

80

100

120

140

160

Average Weekly Wait Times in Fast Track

Average Door to TriageAverageDoor to ProviderAverage Door to Discharge

Min

utes


Figure 8. Example of Average Times in October 2013 vs. October 2014 Bar Graph (Tague, 2005).

10/1-10/7

10/8-10/14

10/15-10/21

10/22-10/28

0 5 10 15 20 25

Average Weekly Door to Triage Times

Times in 2013Times in 2014

Minutes

Date

s

Customer satisfaction is identified by follow-up phone calls using a paper form called

“Post-Discharge Follow-Up Call” (Figure 9). This paper allows the clinical staff member that is

following up with the patient to write notes and comments so further follow-up may be

undertaken if necessary. It is difficult to find the time to follow-up with patients in a busy

Emergency Room and this will be one of the challenges of the Fast Track program. Our ER

currently delegates this task to nurses and PCTs during breaks in patient care. It is not consistent,

as some days are busier than others and some staff are more diligent in making their follow up

calls than others. This follow up applies to the entire ER, not just Fast Track patients. Because of

these barriers, only a small percentage of patients currently receive any follow up contact from

the ER.


Figure 9. Post-Discharge Follow-Up Call Form (Summit Healthcare, 2012).

Long-term standardization.

Since the plans implemented have had such a positive effect, exceeding the ambitions of

the committee, this model must be studied, researched, and duplicated. Caution must be

implemented regarding the program’s early success. While this initial evaluation indicates a

success, additional surveys are recommended in the areas of ER wait times, customer

satisfaction, and door-to-provider times at the three-month, six-month, and twelve-month mark.


These results will hopefully confirm the consistency of the initial results and thereby verify the

solidity of the new model’s effectiveness.

First, all of the newly minted models must be cemented into Facility policies and

procedures. The individual or parties who designed and implemented each particular facet of the

overall improvement model should accomplish this in each particular case. Each newly written

policy/procedure to be implemented must be ratified as per any other new policies, and then they

should be additionally be ratified by the steering committee for verification of interpretation.

Secondly, the model and its policies should have an educational plan developed to standardize

orientation for existing and new employees for these respective departments. Initial stage of this

implementation will be to develop an in-house team of Leadership Coaches (Hays, 2008), who

will develop, refine, disseminate and evaluate the effectiveness of the education program. Once

developed, the individual training modules should be reviewed by the chain of command as

appropriate and by the steering committee. A critical element of training employees to the new

model should include a preceptor program; utilizing those employees within the department who

are already demonstrating: 1-effective early implementation of the original model in their

respective area of expertise, and 2- having quality teaching and training skills. These preceptors,

having a specified training agenda provided by the Leadership Coaches, will orient new

employees to the facility and its new operational model. This continuous effort will help the

model remain consistent and therefore standardized.

One potentially effective strategy in cementing model types like this would be to

publically celebrate its clear improvements in patient care. The facilities customer feedback

scores, the quantifiable decreases in wait times, etc., should all be not only published for study,

but they should also be advertised regionally and even nationally. Education opportunities should


be offered to other facilities within and without of the hospital’s network: inviting administrators

and department heads to our facility as guests to evaluate the improvements first-hand, so they

can consider how our model may be effective in their own respective facilities.

Along these lines, the facility should definitely celebrate its appreciation for its

employees, and all of the efforts and dedication that were needed to implement the program to

such a level of success. Awards of recognition and appreciation should be given to all involved

employees and their families. This show of appreciation should be very public and transparent

that the improvements could not have been developed, implemented or maintained without the

efforts of the employees. These actions are not only deserved by the staff, but they also help a

more positive ‘buy-in’ by the personnel, which will help with long-term consistency.

Finally, the most important element to the equation, the customer, should be included in

the positive improvements that have taken place in their hospital. The ER waiting room and

exam rooms would benefit from posters and pamphlets that show our customers the

improvements we have made in their interests. There should also be a publicity campaign in

local and regional media covering how this facility has adapted to the new developments of

customer needs while increasing safety and decreasing negative experiences in our facility. Press

conferences and news interviews should help bring our efforts into transparency, which is in the

public’s interest.

Another element that should be considered by this steering committee, administration,

and the Leadership Coaches could be a policy developed for vigilance toward future progressive

ideation. The policy is one of maintaining a professional and open administrative attitude for

other new evidence, research and ideas which could help in the same or other areas of the facility

– the attitude should actually be regulated is the one of complacency. Maintaining a progressive


stance will help assure that this and other facilities will not fall into the trap of complacency and

stagnation in any of the areas where the purpose of the hospital – to care for its population – can

be improved upon. Input from employees and the other consumers of our services should all be

reviewed and considered, especially to the level of comparison of developing research.

Conclusion

For too long have health care administrators been indifferent to the needs of their patients

in an ever evolving demographic. There is a need for administrators to become more competent

in promoting a dynamic environment within the emergency department that addresses the

concerns and issues presented by patients and their families. In addition, administrators must be

competent in providing Leadership Coaching to their customers which includes the staff that

provide care within the emergency department. They must take the concerns of the patients and

families and encourage proactive consultation from the staff within the emergency department in

an effort to continue to develop processes such as team triage, team assignments and fast track

departments (Hays, 2008). With compensation from Medicare and Medicaid tied directly to

HCAHPS scores it is paramount to the survival of the emergency department to ensure that all

patient concerns are addressed and process’s developed for new unforeseen issues on an ongoing

basis. In order to become more effective managers and leaders health care administrators must

have ongoing education and training in coaching in an effort to maintain a more effective

management infrastructure and avoid the apathy that had riddled the previous twenty years of

patient care in the emergency department (Hays, 2008).

Expounding on this, most demographic changes within specific areas are often insidious.

This dynamic implies that many of those representing the newer demographic typically have a

knowledge deficits regarding the flow and function of the health care system within their new


geographical location (Meek & Tosello, 2006). Communication and education are paramount to

the improvement and ongoing process of compliance and change. There is an implied fiduciary

responsibility to the customer from the health care system that mandates their proper education

regarding the care and the flow of care within the system that they received that care in (Carret et

al., 2007). Without the delivery of such education the health care practitioners providing the

patients current care are placing their clients at an increased risk for re-admission by not

presenting the information needed for the client to make ongoing informed decisions about their

recovery. Therefore, those individuals identified by the new demographic within the

practitioners geographical area, are subject to higher continuing cost of care that precipitates a

decreased likelihood of payment to the health care system since it is almost inevitable that they

will continue to seek follow-up care at the same emergency department for their continuing

follow up care. With today’s decreasing budgets and increased costs of care and liability it is

paramount that our leader’s foster an increasing awareness for practitioners to provide proper

education for the new demographic of patients. All education efforts should be designed to

minimize patient readmissions over time (Hays, 2008). Although the implementation of new

processes can be exorbitant to the ER budget, the cost of not providing proper education and

implementing effective processes such as fast track, team triage and team nursing can potentially

threaten the survival of the concept of the ER as a viable treatment option within the health care

continuum going forward (Hurwitz et al., 2014).

Ultimately this charter hopes to prove the efficacy of systems such as Fast Track by

performing a two month study in an effort to identify decreased wait times and improved patient

satisfactions scores (HCAHPS , 2014). Primary goals include decreasing door to provider time to

less than 20 minutes, decreasing door to discharge time to less than 130 minutes, and increasing


patient satisfaction scores to greater than 90%. Effectiveness will be surveyed by providing

follow up phone calls to discharged patients in an effort to further assess for adequate education

leading to an increase in compliance with medication and treatment regimens, increases in the

perception of the patient’s health improvement and improved patient satisfaction scores

(Cosidine et al., 2008). All data will be assessed and analyzed on a weekly basis in an effort to

further prove the efficacy of the processes proposed within this study by giving the practitioner

the opportunity to adapt and improve steps within the process on an ongoing basis. By providing

a dynamic study this charter hopes to mirror the dynamic nature of the ever evolving

demographic within geographical boundaries. This should provide a model for future

researchers that will help them keep pace with their evolving patient demographic within their

own geographical location.


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quality improvement paper

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