On April 22, 10 teams participating in CEP America's Emergency Department (ED) Throughput Collaborative pilot program gathered to share their progress over the past six months. This year-long collaborative learning initiative aims to accelerate improvement in ED turnaround time to discharge (TAT-D) with the goal of sharing learned outcomes and best practices with the wider organization.
The teams first came together in October 2013 for a two-day session in which they learned about evidence-based improvement practices and strategized with their teams. Over the next six months, they implemented rapid tests of change and engaged in monthly touch-base calls with collaborative leadership, who provided coaching and encouragement. The question we raised back in October was "could our organizations accelerate change by working together"?
Now we'd finally see data on their progress.
To be honest, we weren't expecting miracles. All of the practice locations had struggled with throughput in the past with long turnaround times to discharge.
What's more, it had been a tough winter in our area. Due to a nasty flu outbreak, ED volumes in the region ran 25–50 percent above normal from late December through February. In addition, participants juggled data issues, competing initiatives, CMS visits and — in a couple cases — departure of their nurse manager.
"We're losing momentum," teams kept saying during our touch-base calls. "Maybe winter isn't the best time to start this."
And in hindsight, we agreed a spring start would have been better.
The Results Are In
So imagine our surprise when we gathered in the conference room and heard the following progress report:
- 120 minutes for ESI level 3
- 60–90 minutes for ESI levels 4 and 5
Although these pilot sites still have work ahead of them, I think it's to safe to say that significant improvements have been made and their experiences will affect all of CEP America’s approach in the future.
So How Did They Do It?
To start with, each hospital implemented one or more of the following practices presented in the November session:
- As a group, the 11 participating pilot sites showed significant improvements in their TAT-D since November. In fact, they improved 50 percent faster than the CEP America organization as a whole. (CEP America staffs 94 emergency departments nationwide.)
- The five hospitals of the Dignity Health system alone saved 210,000 ED patients a total of 5.3 million minutes in the ED — the equivalent of 10 years of waiting avoided.
When the teams gathered to share their learning, several commonalities were found among the most-improved locations.
First (and not surprisingly), they reported receiving excellent support from their medical directors and nurse managers. Second, they tended to focus on front-end process improvement, and several had implemented team discharge. Finally, none experienced a major upheaval like a CMS investigation, construction or loss of nurse leadership.
The teams identified seven key lessons from the first six months of the collaborative.
1. Hold participants accountable. Practices benefited when leaders spent time coaching their teams and holding them to task.
For example, one hospital decided to implement a team discharge process in which a physician and nurse work together to disposition patients. But reports showed it was only happening 64 percent of the time. So the team created a simple discharge form to be placed in every patient's chart:
Team discharge: YES or NO
If NO, explain:
Between the form and regular reminders from leadership, the rate of team discharge improved to 90 percent within just a few weeks. Each team discharge saves an estimated 5-10 minutes of patient time.
2. Define roles and processes. Participants agreed that change required ongoing clarification of what the new process was and of every person's specific role within that process. Successful sites emphasized the importance of consistency (e.g., follow the process every time and not try to change it during the test of change).
3. Adjust during high census. To keep change sustainable, teams needed to have an agreed-on "plan B" that would serve as a back-up process during times of peak volume.
4. Engage everyone in planning and tests of change. Changes were better received when key players were involved. One site accomplished this by forming an Emergency Department Performance Improvement (EPIC) committee. Nurses, laboratory personnel, registration staff, radiology staff, administrators and providers were all invited to participate in planning tests of change and tracking the results. Involvement was high, and openness to change in the department showed a marked increase.
5. Communicate, communicate. Departments identified several effective communication strategies. Some distributed flyers or posted memos as reminders of new initiatives. At others, medical directors attended meetings of nursing and charge staff to provide consistent messaging. Team huddles at shift changes created opportunities to review goals for the day and refocus participants (i.e., let's try to team discharge 100 percent of our patients this shift.)
6. Focus on low- and medium-acuity patients. Participants agreed that it's tough to control length of stay for emergent patients in need of complex care. However, they made better progress when they focused on throughput of lower-acuity patients. They agreed the following were reasonable goals and set their aims on meeting them:
- Team discharge (in which an RN and provider discharge patients together)
- Provider in triage
- Nurture the culture
- Improving turnaround for ancillary services (e.g. laboratory)
- Finding new space
- Lean events
- Immediate bedding
7. Touch base calls. Participants overwhelmingly reported that regular (usually monthly) calls with the collaborative leadership helped them stay focused and on track. In fact, ten of the 11 sites have opted to continue these calls for the remaining six months of the collaborative.
Collaborative participants are continuing their tests of change to improve turnaround times to admission. Many have accelerated their improvement now that the high volume season has abated. In one test of change, one ED decreased its discharge time for level 4 and 5 patients by 80 percent. Impressive!
Another focus for the remainder of the pilot program will be planning for the dissemination of the participants' learnings to a wider audience. I think it will be very empowering to see these practice locations, all of which struggled with throughput in the past, emerge as leaders and role models in our organization.