Back in 2014, Aurora St. Luke's emergency department was struggling with 150+ hours of monthly diversion and an antiquated triage process to serve 65,000 patients per year. Patient experience couldn't be budged from the 53rd percentile, and caregiver engagement was equally low at the 50th percentile. Something had to give.
A Team-Based Approach to Hardwiring Change
Patients were at the very heart of Aurora St. Luke's multi-pronged strategy for improvement. As a busy 650-bed hospital with 95 to 99 percent occupancy, the ED was committed to improving throughput despite increasing patient volumes. Here's how they did it:
1. Collaboration Between Physicians and Nurses.
These days, the ED team considers itself one big family. Teamwork starts at the top with collaboration between the medical director and ED manager to set the tone for the department. In fact, ED manager Haley Kovac, MSN, RN and ED medical director Thomas Rudek, MD work closely together to ensure they're aligned with consistent messages and expectations for their teams.
"As leaders, we haven't lost sight of what it's like to work a shift in the ED every day," explains Jim Terrell, BS, RN, director, emergency services. "So when we ask our team to meet a goal, we want them to understand the why behind the request, the reasons patients are asking us to do something differently and that behind that number is a patient's voice."
2. Using Data to Drive Decision-making.
"In the past, physicians and nurses didn't always share the same focus or vision," adds Kovak. "In addition to, say, asking everyone to use AIDET® in the same way, we use data to align everyone and determine whether or not our process is successful."
So once everyone had been trained on AIDET (Acknowledge, Introduce, Duration, Explanation and Thank you; Read more at StuderGroup.com/AIDET), for example, training was validated by physician and nurse leaders. Data from patient surveys is then reviewed to identify individuals with weak skills for further coaching.
3. Building a Mature Culture.
Because leaders have communicated "the why" around requests and provided training, the team is responsive to course corrections through collegial coaching. If a nurse notices a physician isn't completing patient whiteboards, for example, Kovak shares the information with Dr. Rudek who will openly coach a physician out in the department. And the reverse is true as well.
Transparency rules. Everyone sees everyone else's scores and doesn't take feedback personally. The team understands they have a shared responsibility to meet patient expectations regardless of who is doing the caregiving.
4. Redesigning the Care Delivery Model.
At about the same time that Aurora St. Luke's was rolling out new best practices with Studer Group tools and tactics, it also underwent a major remodel of the ED as it readied for a zero diversion environment.
In addition to converting 38 exam rooms to 67 care spaces, it debuted a new intake model where a team-one physician assistant (PA), two nurses and three techs-triages patients into two groups. Emergency Severity Index (ESI) levels one and two go directly to a room while ESI levels three, four and five are seen in the intake area. Here, their care begins with an exam, lab draw and medications.
150+ hours of diversion per month
ZERO diversion hours
CMS ED National Benchmarks: Below national average
CMS ED National Benchmarks: Well above the national average
Patient Experience: 53rd percentile
Patient Experience: 70th percentile 2nd for EDS with > 40,000 patients
Caregiver Engagement: 50th percentile
Caregiver Engagement: 69th percentile
38 exam rooms
67 care spaces
Antiquated triage process
65,000 patients per year
82,000 patients per year
5. Introducing "Care Cards" to Guide Patients' ED Experience.
When patients arrive for intake, a PA gives patients a care card that explains what to expect and how the different care areas in the ED work. The back of the card is individualized for patients with the names of caregivers on the care team and the status of any tests that were ordered. The card follows the patient throughout his ED visit. A win: Patient satisfaction data shows that patients who receive the card rate the ED more highly than those who don't.
Today, the ED at Aurora St. Luke's is in the top decile for door to provider time-less than 10 minutes- as well as door to pain medication time compared to peer hospitals. In addition, patient satisfaction has jumped from the 53rd to 76th percentile and employee engagement from the 50th to 69th percentile.
"The magic for getting great results? It's consistency," emphasizes Kovak. "Our success comes from four supervisors in the ED-three nursing supervisors and one clerical supervisor-sharing the same message and constantly rounding and meeting with caregivers. If you let your foot off the gas, the numbers take a dive. It's important to always be proactive."
"We like to control what we can control," adds Dr. Rudek. "If our house is in order, we have credibility with other departments when we ask for faster x-rays or lab draws because we're already efficient at everything else."
Haley Kovac MSN, RN, manager, emergency services
Thomas Rudek, MD medical director, emergency services
Jim Terrell BS, RN, director, emergency services