Improving Patient Flow Through the Emergency Department

Abstract

Peggy Ames, manager of information systems, and Lee Kauffman, director of managed care and administrative director of laboratory services, both at Winchester Hospital in Massachusetts, contributed to this column and were co-facilitators on one of several Lean Six Sigma projects launched at the Winchester Hospital ED.Improving patient flow in the emergency department (ED) is a strong complement to improving the inpatient discharge process. Patient flow must be viewed as a hospital-wide system in which the issues causing obstacles to smooth flow are identified and eliminated or mitigated. This overall patient flow needs to be broken into components to facilitate parallel improvement projects. In this column, we will focus only on the processes internal to the ED.ED visits increased 38 percent between 1997 and 2007 (Tang et al. 2010). This steady increase in ED patient volume has put a huge strain on hospital facilities and budgets. Adding more staff and spending capital to expand the ED are not viable options for most hospitals, so EDs must improve efficiency and effectiveness through low-cost process improvement efforts. These efforts can provide the hospital with a triple win:1. Improved patient satisfaction: Less waiting and better lead to satisfied patients.2. Improved quality of care: Standard work and improved flow reduces staff stress and minimizes the risk of patients decompensating or having patients leave before they receive treatment.3. Reduced total cost through higher utilization: More patients can be serviced within the same physical space and without an increase in staff.Exhibit 1 provides a typical emergency department process flow.Providing full details on how to improve all the steps in the ED patient flow exceeds the scope of a column, so we will illustrate key improvement methodologies that, in our experience, are core to process improvement in the ED.START WITH VOICE OF THE CUSTOMER AND VOICE OF THE PROCESSTo gain an initial understanding of the current state of the ED process you must understand how the process is perceived (voice of the customer) and how the process is currently performing (voice of the process).Voice of the CustomerBy using internal survey tools or external services such as Press Ganey, you can determine the voice of the customer - in this case, both patients' and staffs perceptions. Gathering and analyzing this data will provide valuable insight into how the ED processes are perceived. Using tools such as affinity diagrams and critical-to-quality trees, one can boil down general needs to specific measurable needs by translating statements such as I want fast and courteous service to specific requests such as I want to see a nurse within 15 minutes of arrival and I want to be greeted by name.When we started our ED project at Winchester Hospital, the hospital's Press Ganey scores were in the middle range of the hospital's peer group. We targeted two particular patient-related questions in our project; the before and after results are shown in Exhibit 2. These particular question scores show a dramatic rise, but it is interesting that overall scores on all questions also rose dramatically and overall satisfaction with the ED is now in the top 5 percent compared to peer hospitals.Voice of the ProcessThe voice of the process involves determining how the process is currently performing. This determination can be made through many tools and analytical techniques, a few of which we will examine here.Spaghetti DiagramsExhibit 1 shows a linear, well-organized path through the ED, but the real patient flow is not always so perfect. For a better view of the real process, look at Exhibit 3. This is a spaghetti diagram tracing the path that one level 3 patient took at Winchester Hospital. (EDs use a priority level index to determine the level of the acuity for each patient. …