An interview with Dan Smith, MD, Studer Group executive medical director, international speaker, and practicing emergency department physician.
Q: DR. SMITH, WHY IS OPERATIONAL FLOW SO IMPORTANT TO THE HIGH-PERFORMING ED?
A: Just as establishing an airway is critical to beginning effective CPR, efficient flow is key to achieving a high standard of care and positive financial performance in the ED. Efficient patient flow drives (1) quality—so we as providers live our mission to deliver quality care to patients. We don’t want to miss clinical opportunities to administer time-sensitive clinical processes and treatments for serious illnesses like acute Myocardial Infarction, Sepsis and Stroke. (2) safety—by avoiding sentinel events for waiting patients, and (3) positive patient perception of care. “Duration” or “How long will this take?” remains a top driver of ED patient satisfaction in studies from large national patient satisfaction databases year after year. (Studies show that shorter ED wait times closely correlate with quality outcomes and higher patient perception of care.)
Optimizing flow in the ED is also a win for the whole hospital, which faces significant reimbursement cuts based on HCAHPS performance, readmissions and process of care measures. (As the front door to the hospital, EDs set the tone for the patient experience and quality care in the ED prevents readmissions. There’s also a linear relationship between ED perception of care and how inpatients rate their stay on the HCAHPS survey. They go up or down together!)
Q: ISN’T FLOW UNPREDICTABLE AND OUT OF THE HANDS OF THE ED TEAM?
A: Actually, flow is largely predictable. While we do get surges of patients in the ED, we can track historical data to predict the usual arrival patterns and throughput intervals. When we chart these arrivals in parallel with provider and staff capacity, mismatches of capacity and demand often become evident. The reception area inevitably backs up as staff and providers struggle meet the needs of high patient volumes that exceed their care capacity.
Frequently, EDs are overstaffed for part of the morning, but then understaffed for the peak afternoon and evening time. Always consider variations in hourly demand and layer in staff and providers to match it. Since we can identify patient arrival patterns and we already know our bed space and staffing capacity, we simply need to align the two for success by adjusting to meet demand.
Q: SO ARE THERE PRINCIPLES THAT CAN BE FOLLOWED TO DRIVE OPERATIONAL EFFICIENCY?
A: Any efficient flow model will address four key principles: First, recognize that ED real estate is precious. Since we have a defined amount of physical space, we need to utilize it in the most efficient way for patient throughput. Secondly, keep vertical patients vertical! Since we only have a limited number of beds, it’s critical to design flow processes that maximize their use for patients that most need them. Vertical care models are a paradigm shift from the traditional “all horizontal” mentality of the past.
Thirdly, Use ED spaces only for active care management. This ensures we are allocating our precious ED real estate and provider resources for the newest and sickest patients. And last, ensure that there are dedicated people and processes to meet demand. Caretakers need to be at each point in the transition to avoid bottlenecks. Think: “Right patient at right place with right resource at right time.”
Q: HOW CAN WE USE THROUGHPUT METRICS TO HELP US DIAGNOSE OUR ED’S FLOW CHALLENGES?
A: In the EDs that Studer Group coaches, we often see a variety of flow challenges in one of the three major throughput phases. Some have front-end issues (door-to bed time), some have middle issues (bed to disposition time), and some have back-end issues (disposition to discharge or admit). Many EDs experience all three! We prescribe different models for optimizing flow based on our diagnosis of where the challenges lie…and the best way to do that is to identify performance gaps by analyzing trend data for throughput metrics.
With coaching, improvement in these throughput metrics is frequently dramatic. For example, Parkwest Medical Center—an ED that sees 48,000 patients per year in Knoxville, TN—reduced admission cycle time by 32 percent and improved virtual capacity by 18 percent.
Studer Group recommends EDs use a daily dashboard (that is shared with the ED team) to track and measure how actual results in metrics for key throughput segments are trending to goal. (Dashboard goals flow from organizational and ED annual goals.) Performance metrics on the dashboard are tagged green for trending positively to goal and red for not meeting goal. As a result, you can quickly identify both the “wins” and areas for improvement at-a-glance to focus your efforts on improving flow. (If you are a Studer Group partner, log on to Studer Group’s on-line learning lab at www.studergroup.com to watch a short video of an actual pre-shit ED “huddle” using a daily dashboard and download a sample dashboard.)
Q: WHAT IS “SPLIT-FLOW” AND HOW DOES IT WORK EXACTLY?
A: “Split-Flow” (i.e., segmentation flow) is an evidence-based model of care for EDs that typically have opportunities for improvement across the dashboard…a log-jammed ED experiencing surges of patients from all acuity levels, excessive length-of-stay, and a high percentage of left without being seen (LWBS) patients. It’s a comprehensive vertical care model that keeps patients moving forward, rather than back to the reception area.
Here’s how it works: A patient’s first point of contact will be a nurse who does a “quick look assessment” to assign a triage acuity level while a dedicated technician assists and a registration clerk simultaneously does a quick registration. Then the nurse will triage patients into a rapid treatment and intake area or core bed based on triage (ESI, CTAS or ATS) level.
Patients that are deemed appropriate for the rapid treatment area receive a secondary assessment and the provider takes a history, performs an exam, and orders initial tests, treatments, and medications as indicated. Following initial evaluation and treatment, patients are then moved to a “Results Pending” area, a physical care space with a dedicated nurse. A “nurse hawk” who essentially acts as an air traffic controller for the ED monitors how things are changing in triage and the back of the ED, while also collaborating with providers and nurses to prompt test review, look for opportunities to move patients from core or intake/Fast Track beds, and assess Result Pending census.
In coaching EDs to optimize flow, Studer Group has seen some impressive results with Split-Flow. For example, John Peter Smith Health Network (JPS), a large academic medical center in Fort Worth, Texas with 98,000 ED visits per year reduced LWBS and AMA patients by 35 percent in ten months. On some days, they process 60 percent of patient visits using the vertical pathway of Split-Flow in a 24-hour period!
When assessing whether a split-flow model is right for an ED, we frequently engage the ED team in a flow simulation exercise by dividing a tabletop into mock ED rooms. Index cards represent patients with key time points from actual tracking board data. Movement through the “mock” ED is guided by the historical time stamps. Time compression speeds the exercise and log jams and operational inefficiencies become immediately apparent. A running tally of hourly census in reception area and “open ED beds” is kept. The exercise is then repeated using a flow efficiency process like Split-Flow. The difference is frequently quite dramatic.
Q: BUT ISN’T IT TRUE THAT “BOARDING” OR “ACCESS BLOCK” CAN CAUSE SUCH A LOSS OF ED REAL ESTATE THAT IT CAN BE DIFFICULT TO FIND SPACES TO CARE FOR PATIENTS?
A: Absolutely. To hardwire quality and operational excellence in the ED, hospitals must confront the institutional, systemic problem of boarding to free the ED of this burden. This can only be achieved by development of a hospital-wide flow team with engagement of unit managers, physicians, executive leaders, and use of real-time systems, principles, and processes. When a culture of meaningful collaboration is hardwired, there are many effective tactics ranging from deployment of flow coordinators and thoughtful scheduling of elective surgeries, to the use of discharge lounges and daily bed meetings that successfully address this problem.
At Studer Group, we find that when the ED adopts an attitude of “We’ll go first!” by addressing flow challenges within its control, senior leaders and physicians are quick to lend their support on issues outside the control of the ED, such as boarding. Because senior leaders are feeling new urgency from reimbursement pressures to address challenges in the ED, there has never has there been a better time to enlist their support.
Dan Smith, MD, FACEP serves as a senior coach, speaker and executive medical director for Studer Group, working in a variety of areas including medical practices, inpatient and emergency departments. Dan has coached, mentored and lectured at over 200 organizations in the United States, Canada and Australia. He enjoys coaching and speaking on patient and physician engagement, performance excellence in the age of change, physician communication and physician performance feedback.