Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

How One Hospital Improved ED Operations in Just 90 Days

9/28/2016 1:54:09 PM | 4 comments

They say change takes time. But in healthcare, and especially in the ED, we don't always have that luxury.
 
The good news is that with the right approach, we can make a difference quickly. In today's post, we'll look at how Howard University Hospital (HUH) in Washington, D.C., achieved a significant turnaround in throughput and patient satisfaction in just three months.
 
The secret? They focused on culture.
 

Continuing a Proud Legacy

 
HUH was founded in 1862 as Freedman’s Hospital. In its early days, it was one of the only places where former slaves could receive care. Today it’s the only teaching hospital in the country located on the campus of a historically black university. Its busy ED is home to a Level I Trauma Center and sees 60,000 visits a year.
 
Unfortunately, the hospital has struggled financially in recent years. Both the recession and demographic changes have cut into revenue. To reclaim their market share HUH leaders devised a turnaround plan. Their first priority: improving operations in the ED, which admits 75–80 percent of HUH inpatients.
 
At the time, the ED was staffed by a group of talented faculty physicians. But like many smaller groups, they had limited experience and bandwidth to tackle throughput issues, ambulance diversion, and some of the longest wait times in D.C.
 
Inefficiency also took its toll on the team as well as the patients. Provider turnover was frequent. Nurses were especially overextended, and rates of absenteeism were at an all-time high. Unions dug in their heels to protect their members from new changes or demands.
 
In its long history, HUH had never outsourced a clinical department. That thinking changed when CEP America began staffing the ED of nearby Providence Hospital. A few Howard attendings also worked shifts there, and they were impressed by the operational improvements they observed.
 
The physicians brought the idea to the administration, and on April 1, 2016, CEP America began staffing the HUH ED. I came aboard as Medical Director with my colleague Maureen Bell, MD, acting as Assistant Medical Director. Pascal Crosley, DO, the CEP America Vice President who'd helped negotiate the contract, also joined us in the crucial early weeks. We also received invaluable support from Regional Director Matthew Stilson, MD, and CEP America's dedicated team of Practice Management Consultants.
 

Shaping Culture by Example

 
Maureen, Pascal, and I all knew we were walking into a department of great providers. But we also sensed they were pretty demoralized. So from the first shift, we agreed not to lecture, recommend, or advise. We'd start off leading strictly by example and watch how they responded.
 
One thing we really tried to model from day one was ownership. We wanted everyone to feel responsible for providing these patients with quality care in a timely manner. So when a problem arose, we made a point to resolve it by any means necessary. If there was a holdup in the lab or triage, we went straight to the source and handled it personally. Nothing was going to hold us back.
 
Little by little, our efforts paid off. Everyone was very motivated; they just needed permission to change. Interestingly, our invaluable first champions turned out to be nurses and advanced providers. Gradually, the faculty physicians followed suit.
 
Before we knew it, providers were even going out to the waiting room to diagnose and treat minor complaints. The patients were astounded. "I couldn't get seen that fast at the doctors office!" was a common refrain. Some of them had looks of total shock when we handed them the discharge paperwork.
 

Making Great Alliances

 
One thing our leadership team absolutely needed for this turnaround to work was partnership with nursing. As I mentioned above, our nurses were incredibly overworked. So right away, we started looking for ways to ease their burden. Simple changes like discharging our own patients went a long way toward winning their trust.
 
We also wanted to send a message that we were in this together. The nursing director was fairly new and had inherited a tough situation. We made a point of including her in our leadership team and supporting her decisions. She also worked closely with our Practice Management Consultants to improve nurse engagement.
 
Once again, our efforts paid off. Absenteeism among nurses dropped from a record high to a record low. Best of all, they rallied around their director. She's now enjoying a wonderful rapport with her team and seeing great results.
 
Yet another prong of our culture change strategy was to get buy-in from the various unions. Believe me, you can't move an inch in a D.C. hospital without their help. This was one area that I really enjoyed. I talked to the labor leaders, heard their concerns, and showed them how we could work together on issues. Most of all, I tried to show them how improving ED operations would benefit their members.
 
Once again, the talks paid off. The unions have become huge supporters of our ED strategy. It's funny, because everyone’s actually working harder and seeing more patients these days. But it feels like we're actually doing less, so no one's complaining.
 

Bringing On Best Practices

 
CEP America has pioneered a lot of great programs to help EDs run more effectively. After giving our new culture a month or so to take root, we were ready to put some of these into action.
 
Since one of our goals was to increase revenue, we felt that it was very important to improve our ED points of entry. So we started our process engineering at the front door and worked our way back.
 
Some key changes we made: We'd been improving all along, but when we started RME, we kicked our metrics into high gear.
 

90 Days Later

 
How high you ask?
 
Within 90 days, we achieved the following:
  • Overall median LOS dropped by 29 percent
  • LWBS rates dropped by 33 percent
  • TTP decreased from 106 minutes to under 20
  • Volumes rose 18 percent
  • Patient satisfaction scores were the highest in HUH history
Among D.C.'s hospitals, we were now ranked first or second on all Hospital Compare metrics. We were even beating much smaller EDs!
 
HUH CEO Jim Edwards shared this quote about CEP America:

More than anything else, they brought strong physician leadership. On one hand, they gave us access to proven methods they'd engineered and refined. But just as important, they engaged our staff. Now when I visit the ED, I see a staff that is much more empowered, much more enthusiastic. And as each success is achieved and celebrated, it reinforces a culture of continuous improvement and excellence.

And then of course, there are the patients.
 
Recently a lifelong D.C. resident visited the ED with her sister, who has a chronic illness. After discharge, she asked to speak with the medical director.
 
Now usually when I hear that, I expect the worst. But this woman was incredibly appreciative. As it turned out, she was the head of a healthcare nonprofit and well acquainted with the local hospital scene. She told me that this was the most incredible care her sister had ever received.
 
I ended up showing her around the ED, pointing out the changes that we'd made. As we talked, she reminded me of something important: HUH has a special place in the hearts of many Washingtonians. For some residents, it's the only hospital they'll come to when they need care. So we have a special responsibility to them. And when they say they've never been treated so well or so quickly, it matters that much more.


Comments
Savoy Brummer
Great story. A lot of people do not know how important Howard is to the City of DC. For us to be affiliated with Howard is a big deal especially on the East Coast. Moreover, I recently read that the hospital now has a net operations profit of $4M and that was secondary to the good work of the ED! Great win for the patients! #HU#YouKnow
9/29/2016 8:40:37 AM

Lin Hartwell MD
Great article Azmat. That is an amazing story about how leading culture change creates rapid and sustained operational excellence.
9/29/2016 8:40:34 AM

Trish Jones, MD
What an amazing transformation that has occurred under your leadership. I am very proud and inspired by what you all have done.
9/28/2016 3:39:39 PM

Jon Falck
AZ, that is a very powerful and compelling tale. I wasn't aware of the backstory with the providers also working at Providence. Sounds very similar to the drastic improvements that took hold at St Agnes almost immediately after CEP won the contract. Of course... I would expect nothing less having had the pleasure of working with Maureen, Crosley and yourself. You should all be proud.
9/28/2016 3:00:10 PM