Written by Scott Adler
Insight Strategies, LLC

This article was originally published in the August 2023 IEPC Newsletter. Click here to view a PDF of the newsletter.

In most hospitals, more than half of all patients on the inpatient units come via the Emergency Department. If the front door of the hospital doesn’t facilitate great care and a great patient experience (for those discharged as well as admitted), it can be very difficult for the hospital to recover. Unfortunately, stories about struggling EDs have become the rule rather than the exception across the United States. Additionally, these struggles are only exacerbated by the increased volume finding its way to the ED after COVID. Throughput (length of stay), door-to-provider times, patient and staff engagement, left without being seen (LWBSs), elopements, inpatient holds, and diversion hours frustrate clinical staff and administration alike. While there are numerous methodologies that can be used to address these issues (Lean, Six Sigma, etc.), it is important to recognize that regardless of the way in which the problems are addressed there are only a handful of habits that are required for an ED to be successful.

Bringing these habits to life requires changing old habits—both organizationally and in the ED. There are two essential aspects of change that must be adhered to if an ED is able to successfully acquire these habits—engaging front-line caregivers in the design and considering the ED as a system, not a series of discreet steps.

Working with facilities large and small (currently more than 5 million patients are experiencing care each year in facilities whose process redesigns I’ve facilitated) I’ve seen what works. Not a specific process (there are differences site to site depending on a number of variables) but a set of habits that successful EDs take advantage of. Each of these habits is connected and reinforces the others. They sound simple. But don’t be deceived. They aren’t necessarily easily acquired or executed. Here are a few words on each:

Be truly patient focused

Patients come to ED for only one reason—to see a provider. We may know this intellectually, yet we put up roadblocks between the door and the provider. These roadblocks are well intended and make sense when we establish them, but we don’t fully comprehend their unintended consequences (for example, in most EDs, the first person the patient walking in sees isn’t a clinician—it’s a registrar or a security officer). Before you can be truly patient-focused, you have to know what patient-focused really looks like. That doesn’t mean which questions are identified as most important on the patient sat survey. It’s really knowing and understanding what the patient requires—what they want, need and expect—of the service you’re providing.

It is vital that you engage front-line staff in clearly articulating the ideal patient experience and use that as a filter for the process you employ to take care of your patients. Everyone must know what is expected of them and what they’re collectively shooting for.

Creating patient-focused processes isn’t always easy. Clinicians are smart. They’re able to rationalize why what’s best for them is, in fact, what’s best for the patient. That’s why most of the processes you find in health care are built around the staff, not the patient.

Have a source of truth regarding the process

Reducing variation is key to high-quality care and consistent, efficient and effective throughput. There needs to be a source of truth regarding how things are done, including expectations for performance. That means the care process should be documented to the task level because this will drive:

• Consistency in performance
• Consistency in training
• Reduction in variation

This is about more than policies and it’s more than an oral history. If everyone is going to row in the same direction, they need to know specifically what the process is. Too often, the process that the new staff is oriented to is based on how the preceptor does it. If there are more than one preceptors, there will be variation baked into the training. “This is how I do it,” shouldn’t be the standard operating procedure. How it’s done should be in writing.

View the ED as a system, not a series of discreet events

Everything that happens in an ED (or in any system) affects other aspects of the system down stream. You have to address the entire system. In this case, it’s the ED process from arrival to discharge/admit (i.e., you can’t fix triage in isolation). Therefore, if you want to improve the system you need to do three things:

1. Get the system in the room
2. Give the participants a chance to see reality through each others’ eyes. This provides the participants an opportunity to suspend the assumptions they have about the other functions in the system (i.e., the ED RNs understand why the floor RNs might not want to or be able to take admitted patients as quickly as the ED RNs might expect).
3. Allow the functions to put their different purposes together and to commit to them

Remember, it’s about improving the quality of thinking and interactions between the different parts of the system, not optimizing any single aspect of the system.

Ensure the patient is always where the patient belongs clinically

Unfortunately the processes that are in place are often based on incorrect assumptions. For example, our overarching mental models tell us that ED patients need to be in a bed to be treated. That’s why in most EDs patients have to end up in a bed before they see a provider or RN even if they don’t need to be horizontal for their care. The fact is, not every ED patient needs a bed to be treated and not every ED patient needs to own that bed throughout their stay if they should happen to get one at some point in the process. ED patients may physically move through their treatment experience. This concept leads to the consideration that the physical plant can be used more efficiently with the creation of results waiting or other “vertical” space for the patients, such as treatment in progress. However, in order for this to happen, understanding the acuity of patients and where they are in their treatment process is required, otherwise patients will get “lost” in the system.

Treat the sickest patients and manage the rest continuously through to disposition

The traditional process used by the overwhelming percentage of EDs forces clinicians to choose between patients based on acuity. If patients are segregated by acuity based on clinical criteria (not solely ESI designation) the staff can care for patients on the patient’s time, not on the staff’s time. This is different than a fast track, which is typically based on ESI 4 and 5 patients and struggles to be sustained due to the subjective nature of the initial triage. It is more effective to utilize limited clinical exclusion criteria as well as ESI. This segregation of patients should not be time-based (i.e., all patients can get through in 90 minutes).

Full initial triage with an ESI sort will inevitably lead to the idea that “this patient can wait.” This assumes that the system requires patients to wait for care and with this mindset, they inevitably will.

Another trick EDs use is putting a provider in triage, which typically leads to redundancy in the process (if the patient can’t be discharged from triage, the patient often goes through another assessment by the physician in the ED to complete treatment and order additional tests) or a “drive by” interaction between provider and patient that doesn’t fully initiate the treatment process.

Robust air traffic control (facilitating proactivity)

If patients move during the course of their treatment, you have to know where they are physically as well as where they are in their treatment plan. This means someone must oversee the overall flow of patients. The charge RN should be this air traffic controller. Keep in mind that the charge role is a real function not simply a designation. He or she is not the department’s gopher—physically pushing patients upstairs or handling hard sticks. They must do what they are uniquely qualified to do and their duties must be specifically defined (standardized). They need to be able to look ahead and project ED bed/space needs hours in advance to avoid the last minute scramble whenever possible. Understanding the volume and the distribution of that volume over the entire day is a must and they need the tools to manage current volume and anticipate future volume.

A sustained sense of urgency

Every patient deserves a focused, quick (but not too quick) throughput experience. All too often, there isn’t a real sense of urgency throughout the day in Emergency Departments. Usually it takes an emergent patient (a trauma or highly acute patient) or when the ED is slammed before there is a real sense of urgency. It is absolutely essential to maintain that sense of urgency when the department is full or if it’s virtually empty. The struggle is to pick up the pace when needed, if things have been slow. A coach once said to me, “How you practice is how you play.” The same idea applies here. A consistent sense of urgency leads to better quality care and improved patient experience throughout the day, not only when volume goes through the roof.

Continuous communication with the patient and family

The patient and family (or care support system) must be kept in the loop as the care process unfolds. That means that they should be updated every 15 minutes or less, even if you can’t add anything new to what’s happening. Scripting is essential to support the staff in this communication. Too many times I’ve seen ED staff actually avoid talking to patients because they don’t know what to say as to why the process is taking so long. And when they do talk to the patient, it’s very tempting to blame other parts of the system (“Radiology takes so long” or “I’m waiting to get a hold of the floor nurse to give report”).

Closing thoughts

ED throughput struggles are real. Most of my clients tell me the problems they have in the ED are driven by the inpatient units not taking patients quickly enough, the ancillaries are too slow, or the behavioral patients are camped out there for too long. When I hear this, I remind them that typically 4 out of 5 ED patients go home. If you can address the 80% successfully, the other issues are inconveniences, not single points of failure.

When it’s all said and done, remember: It’s a team sport and there are different motivations for different team functions. RNs in EDs today, generally, are less experienced than they were 5 or 10 years ago, which puts pressure on the more experienced RNs as well as the providers. (Adding to the struggles, these new RNs are turning over at an accelerated rate.) The sense of burnout is real and connecting all caregivers to their “why” is essential. The caregiving team must be owners of the process, not renters. Articulating an intentional culture and then operationalizing that culture in the process is key.

Some of this might seem obvious. Some runs counter to conventional wisdom related to the way in which EDs approach their care process. Remember, the way in which we think about our work drives how we do our work. How we think about care in our EDs drives whether or not these habits go from ideas we understand intellectually to ways in which we consistently care for our patients. Challenging the conventional wisdom can be tough.

Please give me a call if you’d like to talk this through or if you have any questions.