Reduced Wait Times, More Efficient Emergency Departments

	Patient care associate logs in a patient at the Kings County Hospital emergency room.

Not long ago, patients entering the adult emergency department at Kings County Hospital Center were met by a security officer rather than a nurse at the front door, recalled Glenda Martin-Grant, RN, Assistant Director of Nursing at the hospital.

So when hospital staff undertook a reorganization of the emergency department using the Toyota lean process improvement methodology, they literally started at the front door.

Now when patients enter the emergency room they are greeted by a friendly patient navigator who directs them to the triage and registration counter. A triage nurse interviews the patient, performs a visual assessment, then identifies the patient’s level of medical urgency. And, about 15 minutes later, the patient is called in to an exam room where a nurse takes vital signs and completes a full assessment – a process that used to take 31 minutes.

The hospital security officer is still near the entrance, keeping patients and staff safe, but the desk has been moved to a less conspicuous spot.

“We’ve engineered a cultural change in the way we work in the area,” Martin-Grant said. “The culture has gone from staff-centered to patient-centered.”

Since 2007, HHC doctors, nurses and staff have been using Toyota lean methodology, known as Breakthrough at HHC, in multiple areas and departments to identify inefficient processes, improve care, and improve the patient and staff experience, as well as generate savings and new revenue. The improvements devised by Breakthrough teams in the emergency departments and across other operations of the HHC system have resulted in an estimated $215 million in combined savings and new revenue.

Throughout HHC, hospital staff members have conducted more than 900 rapid improvement events, week-long problem solving activities, where front line staff members have been able to find solutions to improve how patients were being processed in the emergency room, have identified and removed redundant steps in the process, designed a more patient-centered flow, and evaluated results to ensure sustainment.

At Kings County Hospital, the average wait time from log-in to triage was reduced from 31 minutes to 15 minutes in the adult emergency room, a 50 percent improvement; and from 52 minutes to 20 minutes in the pediatric emergency room, a 61 percent improvement. An article written by a Kings County Breakthrough team and emergency department staff describing the transformation of its ER was recently published in the peer-reviewed Journal for Healthcare Quality and drew national attention.

“For HHC, the ED is our front door. It is often a patient's first introduction to our system and ED patients, by definition, come to us because they have an urgent need that requires expert, compassionate and rapid response to a wide range of clinical conditions,” said Joanna Omi, HHC Senior Vice President for Organizational Improvement and Effectiveness. “Breakthrough provides tools and management processes to make significant improvements to meet patients' needs and frees our outstanding staff to provide the value they are trained to provide without distraction.”

Other HHC Breakthrough success stories from EDs include:

• At Queens Hospital, one of the early adopters of Breakthrough, the time patients spent in the emergency department between triage and seeing a provider dropped from 146 minutes to 60 minutes. Efficiencies achieved through Breakthrough have enabled the hospital to accommodate an increase of more than 50 percent in additional patient volume over the last three years. They also improved their billing procedures to expedite payment.
• Metropolitan Hospital has reconfigured their ED to improve patient and staff satisfaction and safety and get patients to a provider faster. They implemented a new triage process and reduced the total amount of time a patient spends in the emergency room by one hour.
• Lincoln Hospital has reduced the number of no-show appointments in the medicine clinic by 27 percent by ensuring referrals were more appropriate for the clinic services; reduced the length of stay for treated and released patients by 40 minutes; and reduced the time patients spend waiting between triage and seeing a doctor by 25 minutes.

Breakthrough has also allowed hospital ED staff to bring to light issues that not all staff members may initially see as related, HHC officials said. For example, at Kings County Hospital, Emergency Department supplies were kept in four different supply rooms. Through Breakthrough, the hospital created a central storage room, nicknamed "the supermarket," featuring color coding and categorization, and designated one person to provide supplies to the exam rooms.The changes freed up doctors and nurses to spend more time with patients, reduced waste, and realized a one-time initial savings in supplies of $50,000.

Omi said the full commitment of staff at all levels – nurses, doctors, and other employees – is critical to the success of Breakthrough. “They are successful when they use a very consistent approach that they apply daily to the work they are doing so that improvements are profound and sustained,” she said.

May 2012