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Brigham and Women’s Hospital - Emergency Department

  • Location: Boston, MA
  • Award: Evidence-Based Leadership Healthcare Organization of the Month
  • Awarded: June 2012

Brigham and Women's Hospital Emergency Department Ranked One of the Best in the Country for Patient Satisfaction

Major redesign leads to 99th percentile ranking in a national survey

Boston - In 2009, the leadership of the Brigham and Women's Hospital (BWH) Emergency Department had a problem typical of urban hospitals - too many patients and not enough space. Patient care was excellent, but due to long wait times and other inefficiencies, patient satisfaction scores hovered between the 30th and 40th percentiles. However, in just three years, a dramatic turnaround was achieved. Wait times dropped and patient satisfaction shot up thanks to an unwavering commitment to completely redesign every aspect of the department's operations. The obvious solution would have been to build a much larger emergency department, but space and funding only allowed for a small expansion. So department leaders, including Emergency Medicine chairman Ron Walls, MD, clinical director Josh Kosowsky, MD and nursing director Heidi Crim, RN, had to think differently. Walls challenged his team to eliminate wait times, and to completely rethink every part of the patient care process.

A massive effort, using a proven system of lean process redesign, was undertaken to redefine the entire patient experience, from arrival to departure. Every process step was broken down and analyzed, with a focus on eliminating inefficiency and redundancy to better meet the patient's needs.

Dramatically reducing or eliminating waiting time was a big challenge. The average patient was spending more than one hour in the waiting room before seeing a physician. Like many other EDs, the BWH ED used a triage nurse to receive and assess patients. A large portion of the patients were then sent to the waiting room to await the next available bed. Also, patients were registered at the entry point to the emergency department, further prolonging their wait. And finally, as is the case for most teaching hospitals, patients said they were frustrated by perceived inefficiencies - such as having to tell their story multiple times to multiple clinicians.

Walls, Kosowsky, Crim and other ED leaders were confident the patient experience could be vastly improved. So they set out to create a new patient flow with these specific goals:

  1. Decrease the time between when patients arrive and when they see a physician
  2. Decrease the number of patients who leave without being seen by a physician
  3. Decrease a patient's overall length of stay
  4. Improve patient satisfaction
  5. Maintain or improve the department's excellent quality and safety

In 2010 and 2011, construction took place to create a new 12 bed unit (bringing the total number of beds to 53), a completely redesigned patient reception area and a much smaller waiting room. This physical redesign was designed to complement the process redesign.

In the new process model, patients are greeted and rapidly evaluated by an experienced emergency nurse as soon as they walk in the door. They are assigned directly to a bed with a goal of eliminating waiting room time. Registration takes place at the bedside, often after the patient has been seen by the care team.

In 2011, the ED engaged the Studer Group to cement these process improvements by promoting best practices in communication among providers, staff, patients and families. A team of Brigham ED leaders and front-line staff participated in the "Excellence in the ED" conference in the fall of 2011, returning home to share evidence-based tactics with the rest of the ED. Aligning process with performance expectations, the ED utilized techniques such as rounding on patients and providers, "AIDET" training, and "key-words-at-key-times" to hard-wire fundamentals of service into the ED patient experience.

Crim says, "The results have been spectacular."

Today, one year later, the median time for a patient to reach a bed has dropped from more than one hour to less than 15 minutes. Half of all patients are in a bed within 10 minutes of arrival. The average total length of stay has decreased by more than one hour, despite a 6% increase in patient volume. And - most impressively - patient satisfaction scores have risen more than 60 percent. Survey results show patient satisfaction within the Brigham and Women's Emergency Department is now in the 99th percentile nationally.

When asked the keys to their success, Walls, Kosowsky, and Crim are in agreement. They attribute the critical details of the redesign to a powerful partnership between doctors and nurses. They cite the contributions of front line staff. And they credit the dramatic improvement in performance to the commitment, flexibility and professionalism of the entire ED team.

The leadership team and the ED staff of 300 know their work is not complete. As Walls explains, "We think our greatest challenges lie ahead, to maintain and build upon these successes, even as we continuously refine our care to meet the demands of healthcare reform, including providing the best possible care in the most cost-effective manner possible." And do they relish the challenge? As Kosowsky says, "With our remarkable staff, we truly believe everything is possible."

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