Improving patient flow dramatically decreases wait in emergency and inpatient admitting

Recognizing that backups in the emergency department are a result of broken processes throughout the hospital, Provena Saint Joseph Medical Center in Joliet, Ill. redesigned workflow in many areas. In May, 2005, the 517-bed hospital eliminated the emergency department's waiting room and triage procedures and dramatically reduced the time that patients wait before being transferred to an inpatient bed.

In this installment of Straight talk, we look at the patient throughput initiative at Saint Joseph -- one of six hospitals owned by Provena Health in Mokena, Ill. Modern Healthcare and PwC present Straight talk. The session on patient throughput was held on August 4, 2005 at Modern Healthcare's Chicago headquarters. Fawn Lopez, publisher of Modern Healthcare, was the moderator.

Lopez: To begin the discussion, let's talk a little bit about the issues, opportunities and challenges you faced. Will you share with us what triggered the initiative to improve the throughput of patients at Provena Saint Joseph Medical Center?

Brickman: I was brought into the organization in mid July of 2004 to respond to what had become a very competitive market in the fastest-growing county in Illinois. Four individual health systems were trying to develop new stand-alone hospitals as a way to enter and compete in our market, but our employees lacked any sense of urgency. To get their attention, a very clear, very strong message had to be delivered and a burning platform had to be developed to create the motivation for rapid change across all fronts. We focused first on one of the biggest issues we faced: How we brought people into the organization via the emergency department. The experience in the emergency department distorted our patients' perception of their entire stay with us. Many staff members were embarrassed by the reputation the department had for long wait times. My goal was to come in and quickly develop a series of strategies that would address how we deal with internal and external issues.

Mikos: The most significant challenge was a prevailing attitude that it couldn't be done. Many previous leaders had tried to improve patient flow before but were unsuccessful. The staff said, "This is not going to work." Another challenge was that many members saw it only as an emergency department (ED) issue. They did not recognize that there were broken pieces of the process elsewhere as well. It was truly a system problem. For example, we had competing entry points for patient beds. In addition to the emergency department, surgery and the cath lab were requesting beds. To further complicate matters patients were also being transferred internally between inpatient units. Physician offices were sending patients over as direct admissions. All of these entry points competed for beds throughout a 24-hour period.

Pennell: This is a big issue for most hospitals today. Everybody is struggling with some kind of backup in the ED and on the inpatient units. It presents a lot of challenges. It can literally impact the entire organization and involves more than two or three departments. When I go back after we have completed one of these projects and ask my clients, "What are your thoughts?" They say they never realized how much hard work would be involved and how far-reaching these changes would be.

Mikos: Prior to the implementation of our patient throughput solution, patients would get discouraged with the wait and leave the ED. One of the statistics that every ED looks at is the number of people who left without being seen. In January, 275 people left without being seen. In February, which was a tremendously challenging month for us, 565 people left. In June, the first month after implementation, 40 people left without being seen, while 60 people left in July. Our goal is to drive this number down to as close to zero as we can.

Lopez: What steps did you take to achieve this improvement?

Brickman: First, we improved the capacity in our emergency medicine department. From October 1, 2004 to December 31, 2004, we increased the capacity of our emergency medicine department 50%, taking a department that had been built for 47,000 visits annually and increasing it to 75,000. The volume already averaged about 60,000. We did this on time, on budget, and in 90 days. We also opened up additional medical and surgical beds. Meanwhile, we determined what other measures to take. We began to talk to PwC. We explained to them our situation. We described the entire organization, the culture, and the competitive environment. We launched what eventually became a six-month, major redesign of our clinical processes revolving around the ED, impacting almost 50% of our medical center staff. The redesign culminated in a successful implementation on May 23rd of this year.

Lopez: Will you describe the patient-flow process both before and after the patient throughput initiative?

Mikos: We had to look outside the box for something new and different. Before the change, we had the traditional structure. Patients would go to the ED. They would first get registered, which would take 20 minutes. They would then be sent to the waiting room to sit and wait. Eventually, they'd go to triage, which may take 30 minutes. They would then go back to the waiting room. That's all changed. There is no waiting today. There is no triage. We found ourselves making sure there were no "waiting room" signs anywhere. When patients come into the ED today, they go to registration, but we only gather the essential information necessary to begin any diagnostic testing. While the patient is describing his or her symptoms during a brief registration, a nurse is present and listening The nurse determines the acuity: Is it fast track or the mainstream ED? The patients are then immediately sent to one of 47 treatment areas. If you go to our waiting room today, you would, literally, see nobody waiting. I have to say that in the 12 weeks since implementing this model, we have only had to convert back to the old model twice. just for a couple of hours and it was due to a huge influx of patients that came at one time.

Lopez: In addition to the cultural issues, which we have touched on briefly and will expand upon later in the discussion, what were some of the other issues?

Brickman: We had to reorganize our care management processes, case management in our emergency department, bed placement processes, transportation processes and registration processes. The goal was to change the handoffs that were taking place between the entry points to the medical center and the inpatient units. We had to change the mindset of our medical staff. We had to convince them that we needed their direct involvement to rapidly move patients out of inpatient beds to a lesser level of care and, ultimately, to be discharged from the medical center. We had to change the mindset of the management team handling the project. Project management became very, very important. When we set deadlines, we needed to hit the deadlines. We needed to create objective measures of success. Accountability was vital and continues to be the cornerstone of our success. Education and training were very important. Under PwC, our staff designed the solutions. Management didn't develop the solutions or impose recommendations from consultants. That was an enormous change for us. We identified metrics. We defined financial returns in terms of reducing denials for inappropriate stays and identifying the incremental revenue resulting from our ability to increase capacity. We also focused on employee satisfaction, patient satisfaction, and average length of stay. It was and continues to be a process that we review based on data every single day of the week.

Mikos: The key to moving patients through the ED is to have inpatient rooms open. This means all staff members need to focus on making inpatient beds readily available so that we can admit patients quickly. This means earlier discharges and then rapid bed turnaround. Initially, the staff did not see the need nor urgency to make sure that those beds were continuously available. It was definitely a cultural shift to say, "We need to be in a constant state of readiness to accept new patients."

Dugan: I think one reason that the project has been successful is that they did their homework in regards to the assessment. I think the PwC team really spent the appropriate amount of time dedicated to understanding the current practices. What was happening in the current hospital operations. whether it was in the ED, up on the patient floors, or in housekeeping? I think so many past models have been unsuccessful because there hasn't been enough effort spent upfront on the assessment to truly understand the current state of operations.

Lopez: Can you describe some of the concrete changes you made in processes?

Mikos: We had to develop new protocols. In the past, the ED nurse would contact the unit secretary, who, hopefully, could find the unit nurse, to refer a patient. Often, the unit nurse would say she was too busy to take a report at the moment so then you would lose valuable time. Staff would get busy and two hours would come and go. We built a new protocol. The ED nurse receives a bed assignment from central bed management. The ED nurse calls the unit nurse directly, using special cell phones designed for use in the hospital. When ready to give the patient's report, the ED staff calls directly to that unit nurse. If the nurse is too busy, which could happen, then the ED nurse records the report through a system called Optivox (The White Stone Group, Knoxville, Tenn.). The unit nurse is expected to access the patient report within 30 minutes. When the unit nurses receive a call from ED, they know automatically that transportation has been called. Within about 30 minutes, the new patient will arrive on the unit. A number of other protocols were established as well to ensure a continuous, seamless process for patient flow. We no longer allow individual departments to negotiate for beds -- they have to go through central bed management. Provena Saint Joseph Medical Center invested in a computerized bed-tracking system from Tele-Tracking (Technologies Inc., Pittsburgh, PA) to help us. We were on somewhat of an archaic paper-and-pencil tracking system. The technology has three pieces: 1) Central Transportation is notified electronically when a patient is ready to be discharged; 2) Housekeeping is notified electronically by the transporter discharging the patient that a bed needs to be cleaned; 3) Once the room has been cleaned, housekeeping sends a message through the system that the room is ready to receive a patient.

Lopez: Joan and Fran, what's your perspective? How does this project compare to others?

Deming-Murphy: There was a lot of concern about the lack of accountability across all of the working groups, which involved approximately 75 people. I often heard, "Sure, I could do this and make this change, but who is going to keep the next department accountable? I will do it, but they will never do it." That thinking did change, but it changed over a period of months. The staff really wanted to hear Jeff and Kathy say, "We are going to do this." I heard a lot of people say, "Jeff said this. Kathy said that. Did they really mean it?" Training is essential. Training was a very black-and-white signal that implementation was real. It was important enough to be mandatory. Food was served, sending the message that this was very important. The training took three weeks and involved 1,000 to 1,500 staff members. It was held at different times of the day and night, acknowledging that the night shift doesn't have to be here at 10 am when they are supposed to be sleeping.

Lopez: What surprises did you encounter -- good or bad?

Deming-Murphy: Staff members were making a lot of changes and they didn't always get everything right the first time. The message from leadership was: That's OK. How can I help? Kathy and I pretty much spent the week together and went everywhere in the hospital and joined up with other senior leaders as we needed to problem solve. I saw a change from the beginning of the project. Staff members were really talking about problem solving -- not blaming. The patient became the focus as opposed to the department.

Pennell: In the projects we have worked on in the past, most of the staff members are on board by the time we start the implementation. They feel comfortable that the change is going to happen. This group, interestingly enough, took some time. After two or three weeks of implementation planning, we, the PwC team, were saying, "We still don't see it. We still don't see this level of commitment." Joan and I had a chance to meet with Jeff and Kathy, and to their credit, they activated and really jump-started again the whole message around leadership and commitment. This really made a difference.

Lopez: What exactly did you do?

Brickman: We reminded everybody about why we got into this engagement. We reminded folks about the community's perception of our medical center. We had some very interesting and pointed discussions that lasted three hours in length with some individuals. We rounded. We were very visible. We shadowed the key process leaders, we asked questions, and we talked about where we wanted to be. Kathy and I were in the emergency medicine department on almost a daily basis. We talked to people leading our transport effort. We talked to people doing our case management effort. We really pushed very hard. We were relentlessly persistent. We dug in even harder and people said, "O.K. We are going to get on board."

Mikos: We emphasized that the patient throughput challenge belongs to everybody. For example, it was essential for housekeeping to understand the importance of having rooms cleaned in a timely manner. Patient transporters needed to understand that moving patients needed to happen in a very timely manner. It wasn't as though the ED was any more or less important than housekeeping or the transporters. Everybody was elevated up. Their piece to this puzzle was essential.

Deming-Murphy: PwC was able to watch this process. So after Jeff had been in the ED, a nurse came up to me and said, "Jeff was down here yesterday. He shadowed me and asked me what I thought." She was every excited.

Lopez: Will you tell us about concrete results and how quickly you experienced them?

Mikos: We have a dashboard that measures our outcomes and everyone owns a piece of it. ED, case management, environmental services, central transportation, admitting, nursing units, lab and radiology all review outcomes at a 4:30 p.m. meeting daily. There are three important benchmarks that look at length of time in the ED: fast-track patients, patients that go to the ED and go home, and patients that go to ED and are admitted to the hospital. We have a benchmark of 90 minutes for the fast track. We are actually at 86 minutes for that benchmark. For the second group, the patient should come into the ED and leave in 3 hours. We have achieved that benchmark 62% of the time. For patients who get admitted, we have a four-hour benchmark, which we have achieved 65% of the time. These measures are for a 24-hour period in which we see an average of 180 patients. Our average length of stay for all patients is 2.8 hours, which has dramatically gone down. We also measure the patients' perception of their ED experience. We use Press Ganey (Associates, Inc., South Bend, Ind.) to look at that. Before the change, the perception wasn't good, and we knew that. Just looking at eight weeks of data, we are not where we want to be, but are certainly moving in the direction we want to go. We have been able to move 20 percentile points in eight weeks, which is phenomenal on Press Ganey. In January and February our scores were in the 30th percentile. Since the change, we are achieving 70th and 80th percentile rankings. The results are definitely a statement that the experience is far more positive than it ever was before.

Lopez: What are you going to be doing to sustain or to continue to build upon the progress?

Brickman: Last week, we started saying, "OK. What is the next series of benchmarks that we are going to set? After one quarter of experience, let's take a look at which ones we continue to meet and now let's set the standards higher." Also, we have begun to share information with our staff in cases in which we have identified other issues that we need to solve. For example, in radiology we found some significant process issues that we have begun to reengineer. To improve our throughput, we have to have a greater presence of diagnostic imaging equipment in our emergency medicine department. About 33% of all of our images are done for the ED. Well, doesn't it make sense to bring more of the imaging to the patient rather than to bring the patient to the imaging department? That cuts down on the handoffs and improves process time. We are going to look at that and head in that direction. We are going to find other opportunities. The more we meet, the more we evaluate our processes, the more we meet benchmarks, the more we are going to continue to use this approach throughout the organization.

Lopez: What did you do to convince the staff of your commitment to this process?

Brickman: I spoke very directly. I spoke frankly. I made it clearly understood that there was no backing away from where we were going. I even took out an ad in the paper in which I promised our community that we shared the concerns that they expressed in the newspaper through letters to the editor. I promised them that we were going to do something about it. And any time we saw one of our people flinch, and any time we saw one of our people decide that they didn't want to buy in, we sat down with those individuals and told them they could either stay on the bus or they could get off of it. Did we negotiate somewhere along the line? Yes, but we waited until the very last moment to make changes in terms of schedule or manner of implementation. We held individual team captains accountable before a very serious group of managers and consultants. Team captains had to come in and report on their timelines. And if you didn't think there was a level accountability before, just walk into that room and tell them why you are not going to meet the deadline. It was not a fun place to be. If we said it once, we must have said it 100 times, "We will not allow this to fail. Failure is not an option. We want to know who is not buying into this initiative because we will have a personal conversation with them."

Lopez: How did you display your personal accountability for this project?

Brickman: A big issue for us was the public perception of the medical center. Everybody was talking about it except us. I felt that it was important for our institutional credibility -- both internally and externally. to acknowledge the concerns of our staff and our public by taking out a full-page ad. In the ad, we said, "This is the new Provena Saint Joseph Medical Center. This is what we are doing to respond to your concerns. This is what we are doing to improve our emergency medicine department. Our commitment is that we will make this a better emergency department and you will want to come here for your patient care."

Lopez: You basically held yourself accountable to the public.

Brickman: Yes. I think that became a driving force for me. I made a promise, I made a commitment, and I went on record in doing that.

Lopez: What was the employees' reaction?

Mikos: I think they thought it was very gutsy. But it came off very sincerely. I think it was gutsy because this happened in the fall of 2004 before we hired PwC or developed our throughput solution.

Lopez: What was your medical staff's response to this initiative at the beginning?

Mikos: I think there were some who were disbelievers. We were asking them to change some of the ways they practice. An example is when the ED physician would call an attending physician to discuss an admission, the ED nurses used to take pages of orders. What that did was slow down everything. We came up with a short order form, allowing the ED physician to set up some orders -- enough to care for the patient for the first three hours on the inpatient unit. Some medical staff members resisted the change initially, but have accepted it as they see the overall process dramatically improving. There were periods when staff wanted to waiver a bit, but quickly realized that procedures were established for desired outcomes. Deviations had the potential to damage our whole new process. It was hard at times. After the implementation, Jeff walked into the ED one weekend and identified that nursing had converted back to the old way of triaging patients. It was quickly communicated that our efforts would be focused on the new world order and we would not be going backwards. Our efforts were focused on our patients and their experience at the medical center.

Brickman: We did a lot of other things along the way, leading up to the implementation, to gain the acceptance of the medical staff. We expanded the capacity of the emergency department. We made a major investment in nursing. We responded to a lot of operational issues. We involved the medical staff in decisions -- where they had not been involved before. We made the physicians part of the design team. We had been able to bond with a number of key medical directors, including the head of our emergency medicine department. He became what we are now calling one of our "passionate champions". He spoke out in front of other leaders of our medical staff and said, "Just hold back. We are seeing more done in our department in the last three months than I have seen in the last 10 years. Just continue to work with these people." He paved the way for other leaders to follow.

Lopez: What about the payers? Has this initiative had an impact on your relationship with them?

Brickman: It is too early to know, but I imagine what we will see is that the number of denials for inappropriate stays will be reduced. In just one month, we have already seen a major reduction in our Medicare length of stay by seven-tenths of a day. We have seen a large number of inappropriate admissions move to an outpatient setting. I think it will have a significant impact on patient satisfaction among the members of the plans. I think this is going to make our organization more of a preferred destination for some of the large membership plans, which many of these insurers represent. It is early. I think a lot of our payers are watching what is happening in Joliet.

Lopez: And the employers?

Brickman: Well, I think we will continue to raise the visibility of our success with our employers. I also see other tangible results as well in terms of business leaders working with us to advance other community initiatives.

Lopez: Has this initiative had an impact on the quality of care?

Brickman: I would take a look at a number of issues in terms of how rapidly we have been able to bring our patients to treatment. From just a gut level, I have to believe our care has improved substantially. We don't see people walking away from our medical center. When we look at a comparison of the time it takes for a handoff to occur from our emergency department to an inpatient floor, we have shaved almost two hours off of that process. We were at three hours; now we are down to an hour or less. I have to believe our mortality and morbidity statistics will improve as a result of this. We were already a pretty solid organization in terms of some of our key quality indicators, but I think this is going to help advance those indicators.

Lopez: What role did your board members play?

Brickman: We brought them right into the trenches. We shared with them a lot about the basic issues and they began to add stories of their own. They wanted the change even more than we did because their neighbors and family members all had a story to share along the way. Using those stories with key stakeholders made the organizational urgency to solve this issue so tangible and so relevant that I don't think that anybody could mistake the level of commitment that the entire group had.

Lopez: What's next?

Mikos: I think we can start to apply what we have learned from System's thinking with patient throughput and our successes to other challenges that we face. I think this project has positioned us well as a team to succeed with those other difficult issues.

Brickman: We are advancing a number of key strategic service lines as well as advancing a number of strategic academic affiliations which will further expand our clinical offerings within our region as we become more a regional referral center.

Dugan: Provena Health is also addressing improvement around clinical documentation, charge capture, and coding practices across the system. There are currently investments being made in staff resources and training and education. Furthermore, as is a theme with the patient throughput engagement, Provena has implemented a system to measure the improvements associated with these initiatives. It's a win-win for the staff involved and also the physicians as they further understand the importance of linking documentation to quality.

Key steps to build a successful patient throughput initiative:

Have a clear vision;
Get your stakeholders on board early;
Involve staff in process redesign;
Hold people accountable;
Develop benchmarks and metrics to measure performance;
Develop a thorough training program.

Want to learn more about patient throughput initiatives?
Contact: Frances Pennell, partner, at (646) 471 1780 or click here to send her an email or visit PwC on the web at pwc.com/healthcare.

Participants:

	Kathleen Mikos VP Patient Care Services Provena Saint Joseph Medical Center Joliet, IL
	Joan Deming-Murphy Director PwC New York, NY
	Frances Pennell Partner PwC New York, NY
	John Dugan Partner PwC Philadelphia, PA
	Jeffrey Brickman Chief Executive Officer Provena Saint Joseph Medical Center Joliet, IL
	Fawn Lopez Publisher Modern Healthcare Chicago, IL

The views expressed by Straight Talk participants are not necessarily the views of Modern Healthcare, Crain Communications Inc. or PwC. Special advertising supplement and educational session provided by PwC.

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