Rediseno_rapido_de_un_Departamento_de_Emergencias_ - Verónica Bernal

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C O N C E P T S
Daniel W. Spaite, MD*‡
Fran Bartholomeaux, RN, MS‡
John Guisto, MD*‡
Elizabeth Lindberg, MD*‡
Becky Hull, RN, MS‡
Alicia Eyherabide, RN, MS‡
Sally Lanyon, RN‡
Elizabeth A. Criss, RN, MEd*
Terence D. Valenzuela, MD, MPH*‡
Carol Conroy, PhD*
From the Arizona Emergency Medicine
Research Center, the Department of
Emergency Medicine, College of
Medicine, University of Arizona,* and
the University Medical Center,‡
Tucson, AZ.
Received for publication
November 8, 1999. Revisions received
November 3, 2000; May 24, 2001;
and September 10, 2001. Accepted for
publication October 11, 2001.
Address for reprints: Daniel W.
Spaite, MD, Arizona Emergency
Medicine Research Center, Arizona
Health Sciences Center, Box 245057,
Tucson, AZ 85724-5057;
520-626-7957, fax 520-626-2480;
E-mail dan@aemrc.arizona.edu.
Copyright © 2002 by the American
College of Emergency Physicians.
0196-0644/2002/$35.00 + 0
47/1/121215
doi:10.1067/mem.2002.121215
See related article, p. 159.
Academic emergency departments are traditionally associated
with inefficiency and long waits. The academic medical model
presents unique barriers to system changes. Several non–
university-based EDs have undertaken process redesign, with
significant decreases in patient waiting time intervals. This is
the presentation of a rapid process redesign in a university-
based ED to reduce waiting time intervals. We present the
application of a process-improvement team approach to evalu-
ate and redesign patient flow. As a result of this effort, the
median waiting room time interval (triage to patient room)
decreased from 31 minutes in January 1998 to 4 minutes in
July 1998. ED throughput times also decreased, from 4 hours,
21 minutes in January 1998 to 2 hours, 55 minutes in July
1998. Urgent care waiting room time intervals decreased from
52 minutes to 7 minutes and throughput times from 2 hours, 9
minutes to 1 hour, 10 minutes. Patient satisfaction evaluations
by an independent institute demonstrated dramatic improve-
ment and establishment of a new benchmark for academic EDs.
Process redesign is possible in a busy, complex, tertiary-care
ED, with decreases in waiting time intervals and improvement
in patient satisfaction. Major sustained support from top-level
hospital administrators and physician leadership are funda-
mental prerequisites. With these in place, a process improve-
ment team approach for evaluating and redesigning the patient
care system can be successful.
[Spaite DW, Bartholomeaux F, Guisto J, Lindberg E, Hull B,
Eyherabide A, Lanyon S, Criss EA, Valenzuela TD, Conroy C.
Rapid process redesign in a university-based emergency
department: decreasing waiting time intervals and improving
patient satisfaction. Ann Emerg Med. February 2002;39:168-
177.]
Rapid Process Redesign in a University-Based
Emergency Department: Decreasing Waiting Time
Intervals and Improving Patient Satisfaction
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I N T R O D U C T I O N
The structure of an academic medical center often pre-
sents unique barriers to system redesign, even when the
design is aimed at improving patient services. In recent
years, several non–university-based emergency depart-
ments have undertaken process redesign efforts that have
led to significant improvements in patient satisfaction,
specifically in patient waiting times.1 We present such an
effort initiated between hospital administration and aca-
demic emergency physicians at a university-based medi-
cal center.
At University Medical Center (UMC) in the early
1990s, the ED volume was approximately 32,000 annu-
ally. As a result of a projected increase in patient volume, a
new ED was opened in 1994. Subsequent years yielded
significant increases in volume, reaching 48,000 in 1996.
By the end of 1997, the ED had ground to a halt, with
extremely long waits, large numbers of disgruntled
patients leaving without being seen by a physician, and
overall inefficiency related to providing patient care ser-
vices. The ED was a source of many complaints, and in
late 1997, the hospital’s chief executive officer discussed
the possibility of a major improvement initiative with the
leaders of the academic division of emergency medicine.
The goals of this joint effort were to improve overall effi-
ciency and to satisfy patients.
UMC is a traditional university health sciences center in
a medium-sized metropolitan area (population 750,000).
The hospital has approximately 350 acute-care beds and
provides full tertiary-care services (Level I trauma, pedi-
atric critical care, neonatal intensive care, high-risk
obstetrics, and organ and bone marrow transplantation).
The ED has 4 fully equipped trauma bays, 12 acute medi-
cal rooms with cardiac monitors, 7 intermediate beds,
and 9 urgent care (UC) beds. The UC portion of the ED is
an integrated fast-track unit that sees approximately 35%
of ED volume.
R A P I D R E D E S I G N P R O J E C T D E V E L O P M E N T
The theoretic construct centered in the belief that the cul-
tural, operational, and process changes required to
improve the service provided to ED patients could be
achieved by a combination of (1) a major commitment by
senior hospital administrators, (2) emphasis on emer-
gency physician leadership, and (3) proper application of
organizational resources by using a multidisciplinary
process-improvement team approach.
The improvement project focusing on these areas for
change began in January 1998. The first change was to
name a senior faculty member from the division of emer-
gency medicine as administrative director of the ED. The
administrative costs for this full-time position were borne
by the hospital in a contract with the college of medicine.
The director reports to the hospital’s vice president for
patient care services. The director works collaboratively
with a registered nurse who serves as patient care manager.
The director has responsibility and authority for adminis-
tration, hiring, and firing of nonphysician personnel, and
operational (wage and nonwage) and capital budgets.
The decision to have a physician faculty member in the
role of a full-time hospital administrative director was
unprecedented within the medical center (a nonprofit
corporation separate from the medical school). However,
it was clear that the many previous attempts to fix the ED
had ultimately failed in a morass of faultfinding. Previous
evaluations by the hospital had concluded that the prob-
lem with the ED was inadequate physician staffing, varia-
tions in physician practice, and lack of physician commit-
ment to addressing the hospital’s issues. On the other
hand, evaluations by the physicians had concluded that
the hospital did not provide adequate nonphysician
staffing, efficient processes, rapid turnaround time for
diagnostic studies, or quick inpatient bed availability for
timely admissions.
Because of this longstanding gridlock, the leaders of
the hospital and the emergency medicine faculty group
agreed that the only way to succeed would be for the his-
torical tug of war to end. By appointing and funding a
physician director, the hospital had someone who was
theirs and who also had clout with the physicians. At the
same time, the physicians had a colleague who had re-
sponsibility and authority for process, personnel, and
budgets in the ED.
The project was initiated with the support of UMC’s
Strategic Initiatives Department. Under the leadership of
the director and patient care manager, multidisciplinary
process-improvement teams were formed. Each process
improvement team included at least 1 senior hospital
administrator (vice president), as well as appropriate
physician, nursing, and ancillary personnel. Team mem-
bership was no less than 8 and no greater than 12. Each
team wasguided and supported by a trained facilitator
from the strategic initiatives department. Teams met on a
weekly basis using the following process: initial discus-
sion, data collection, data analysis, process evaluation,
recommendation formation, and presentation of recom-
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throughput times, a decrease in patients who left without
being seen, and improved patient satisfaction.
P R O J E C T I M P L E M E N T A T I O N A N D O U T C O M E S
Recommendations from the process improvement teams
were approved by the senior hospital administration be-
tween February and April 1998. The project recommen-
dations were implemented from late April through June
1998 (Table 1).
The process improvement team evaluating internal
procedures and staffing found numerous challenges.
Rooms in the ED/UC areas were frequently full, backing
patients up into the waiting room for long periods of time.
A 1996 consultant report concluded that the new ED was
already at capacity at 46,000 annual visits. The only way
to decompress the department was to use the current beds
more efficiently and to add beds in the hallway.
The first problem identified by the process improve-
ment team was staffing patterns. All nursing zones had at
least 1 monitored bed, often resulting in less ill patients
competing unsuccessfully for nursing resources. In addi-
tion, nurse staffing had lagged far behind volume in-
creases. The team recommendation was to change the
nursing zones from 5 or 6 beds per nurse to no more than
4 beds per nurse. This change increased nursing availabil-
ity and redistributed nursing resources so that each zone
contained similar patients. By redistributing nursing re-
sources, less ill patients were not held hostage to sicker
ones and could be more efficiently treated. In addition, a
nurse was added to staff 5 nonmonitored hallway beds for
16 hours a day. The changes in nurse staffing yielded an
increase of 11.2 full-time equivalents (23%).
The team identified the processing of orders and tele-
phone communication as another constraint in patient
flow. A single UA was responsible for both tasks. Analysis
revealed that answering the telephone often consumed
mendations to senior hospital administration. Specific
teams were established to evaluate staffing and patient
distribution, registration and triage time, interaction
between the ED and laboratory and diagnostic radiology
departments, and inpatient bed availability (Table 1).
Data gathered for analysis included triage time, regis-
tration time, time of arrival in room, and time of disposition
from the department. Triage, room arrival, and disposition
times were handwritten on the chart and subsequently
entered into the hospital’s information system by a unit
assistant (UA). Registration time was entered electroni-
cally at the time of registration. Additional times specific
to the laboratory and diagnostic radiology departments
were gathered from logs maintained by each specific de-
partment.
Patient satisfaction was evaluated by using 6 validated
questions (Figure 1).2,3 Patients or proxies were con-
tacted by telephone in the month before change imple-
mentation (April 1998) and in the month after implemen-
tation (July 1998). The end points of effectiveness to be
measured for the redesign project were a decrease in
patient waiting room time, a decrease in overall ED/UC
Table 1.
Process improvement changes.
Staffing/internal process:
Decreased nursing ratios from 6:1 or 5:1 to 4:1
Rearranged nursing zones to create 1 zone with no monitored patients
Added a new intermediate level (nonmonitored) zone by adding 5 hallway beds
Doubled UA staffing and separated responsibilities into telephone-communication
and paperwork-order processing
Increased emergency medicine resident staffing by 25% (July 1, 1998)
Triage-registration
Status board monitors in triage
Brief triage and place patient immediately in room
In-room registration
Doubled registration staff
Two-way radios for communication between triage nurse, charge nurse, and
registration staff
Diagnostic radiology
Electronic order entry
Tripled dedicated ED radiology staffing
Located new radiograph printer in ED
Radiographs hung immediately, irrespective of whether old films available
Laboratory
Electronic order entry
Bar-code labeling done in ED
Bright visual cue for laboratory staff
ED laboratory samples take priority over all other laboratory samples
Bed availability
ED-based nursing admit team
Figure 1.
Patient satisfaction survey questions.
1. How would you rate your waiting time?
2. How would you rate the courtesy of the ED staff?
3. How would you rate the overall care that you received?
4. Did you have to wait long to see a physician?
5. Did you have to wait long for your radiograph or laboratory results?
6. Would you recommend this ED to your friends or family?
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this position. The single UA was responsible for answer-
ing incoming calls, initiating pages for nursing and physi-
cian staff, and transferring calls to patient rooms. These
activities precluded efficiently carrying out the other
responsibilities (eg, laboratory and radiographic order
processing and initiating inpatient beds). In response, a
new 24-hour-a-day UA position was created, separating
order processing from the communications process.
The evaluation of physician staffing found that ED vol-
ume had increased by nearly 50% over the previous 3
years. Although faculty coverage had increased by 54%,
emergency medicine resident coverage had increased by
only 20%. During this time, both the emergency medi-
cine residents and the residency director noted the educa-
tional experience was compromised as a result of the
dramatic increase in the number of patients seen per resi-
dent. The residents also noted a decreased ability to inter-
act with attending physicians because of increased patient
volume. This prompted a request to the college of medi-
cine to increase the emergency medicine residency from 8
to 10 residents per year, allowing an increase of 25% in
ED resident staffing. Although the justification for the
residency expansion was made purely on educational
grounds, the parallel needs of education and service were
both met by increasing the numbers.
Before the changes, the ED used a traditional triage and
registration process. When patients presented, a triage
nurse performed a relatively complete nursing assess-
ment. Unless an emergency condition was present, the
patients would wait in line to be registered. Then the
patients would remain in the waiting room until all infor-
mation had been entered into a computer and a patient-
care record was printed at the ED or UC nursing station.
The paperwork would then be placed in a bin to await
room assignment. When a room became available, a nurse
or patient care technician (PCT) would go to the waiting
room and bring the patient to his or her room.
This process was completely redesigned. Now, the
patient arrives in the waiting room and goes to the triage
nurse, where a brief triage is performed and a decision is
made regarding whether the patient should go to UC, a
nonmonitored ED bed, or a monitored ED bed. The chart
is handwritten, available immediately, can be initiated
from any location in the department and requires no wait-
ing for data entry or subsequent printing. The room status
boards in the ED and UC are visible to the triage nurse
through a television monitor, allowing the triage nurse to
assign patients to open rooms. All nursing and registra-
tion staff have 2-way radios that allow for immediate and
continuous communication. The final process is as fol-
lows: the triage nurse does a briefassessment, documents
on a chart, identifies a room, radios both the charge nurse
and registration staff of the patient’s destination, and then
the patient is placed in a room.
The nurse in that zone greets the patient and does a
complete nursing assessment. Often, the physician will
also be in the room and may obtain a simultaneous his-
tory. Soon after room assignment, the admitting clerk
brings a mobile computer dumb terminal into the room
and plugs into the hospital’s central information system
through a standard data port. Registration is performed at
the bedside, and patient labels are generated at the nursing
station. The financial aspects of the visit are completed on
discharge, completely unlinked to the registration process.
Analysis of registration staffing revealed that to do in-room
registration, staffing of admitting clerks would have to be
nearly doubled.
Evaluation of diagnostic radiology identified 2 major
problems. First, the process of ordering and obtaining
radiographs was cumbersome. Second, the volume of
radiographs had markedly increased during recent years,
whereas radiology staffing had not.
The existing process of obtaining a radiograph included
the physician writing (often illegibly) on a radiograph
order form. The UA would then call the radiology techni-
cian (or page them during the hours that no dedicated
radiology staff were scheduled), often interrupting a
radiograph being done on another patient. When the
technician was ready to do the radiograph, he or she
would come to the nursing station, retrieve the radiograph
order, go back to the radiology area, and electronically
enter the information. Then the technician would trans-
port the patient from his or her ED room to the radiology
suite and perform the radiograph. The patient was re-
turned to his or her room after film processing. Whereas
the radiology suite and the digital information processor
were located in the ED, the film printing actually occurred
in central radiology, more than 100 yards away. A film
librarian was responsible for retrieving and labeling the
films, getting any old radiographs, and delivering them to
the ED. Often the film librarian would accumulate multi-
ple patients’ films before bringing them to the ED. Time
sampling revealed that mean time from radiograph order
until the films were available to the emergency physician
for review was 77 minutes.
In the revised process, the UA transcribes the physician
radiograph order electronically. The order is electronically
transmitted and printed in the ED radiology suite without
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were too busy to accept the patient. The throughput inter-
val for UC patients decreased by 47% (Figure 5).
The improvements in time intervals occurred despite
the fact that there were significant increases in ED/UC
volume every month when compared with volumes in the
previous year. The overall volume in 1998 was up 17%
over 1997. Table 2 places the process changes, on the
interruption of the technician’s current activities. A film
printer was placed in the ED radiology suite to rectify
the problem of distant film printing. Delivery of old
films from the film library was uncoupled from hanging
of the films. Radiology staffing was increased from 1
technician 16 hours per day to 2 technicians 24 hours
per day and a radiology assistant 16 hours per day. The
process yielded order-to-hang-time intervals of 9 to 15
minutes in the months after redesign (an 80% to 88%
reduction).
The existing laboratory process included the physi-
cian’s written order being sent with a specimen to the lab-
oratory, where it would sit in a collection bin until a labo-
ratory technologist was available to electronically enter it
into the system. This would lead to the generation of a
bar-code label that was attached to the specimen. The
specimen was then placed in the appropriate area for
analysis. In any given collection bin, there might be as
many as 20 to 30 specimens awaiting testing. Although,
theoretically, ED specimens were “stat,” there was no
visual cue to identify the specimens. Data analysis found
that only 88% of specimens were analyzed and reported
to the ED within the optimal targets set for the various stat
tests. These targets are time ranges mutually agreed on by
the ED and laboratory administration.
With the redesigned process, the UA performs elec-
tronic order entry, including bar-code labeling. The labels
are a unique color, which easily identifies ED specimens
throughout the entire transport and testing process.
When a specimen arrives in the collection bin, it is now
treated as the number one priority and is completed
ahead of all other laboratory samples. After the imple-
mentation, the number of specimens available within the
target range increased to 94%.
The multifaceted process changes resulted in dramatic
improvements in waiting room and throughput intervals.
Figures 2 and 3 show the waiting room intervals (time
interval from triage to patient room) for ED and UC
patients from January through December 1998. These
data reveal significant reductions in the medians of 90%
in the ED and 91% in UC. Figure 4 shows the effect on ED
throughput intervals (interval from triage to patient dis-
position). The throughput time for admitted patients was
found to decrease by 27% between January and December,
whereas nonadmitted patient throughput times declined
by 31%. The addition of an admitting registered nurse-
patient-care technicians team 12 hours a day to transport
patients upstairs, enter their data into the unit computer,
and perform routine inpatient admitting duties allowed
admissions to occur even when inpatient units said they
Figure 2.
ED waiting room interval.
1:04
0:57
0:50
0:43
0:36
0:28
0:21
0:14
0:07
0:00
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1998
Mean time–
83% decrease
Median time–
90% decrease
Figure 3.
UC waiting room interval.
1:12
0:57
0:50
0:43
0:36
0:28
0:21
0:14
0:07
0:00
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1998
Mean time–
84% decrease
Median time–
91% decrease
1:04
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basis of our subjective hypothesis, in rank order of effect
on patient waiting room time and overall ED/UC through-
put times. In addition, it gives the approximate costs and
delineates the full-time equivalent associated with per-
sonnel additions, when applicable.
Three prospective methods for tracking patient satis-
faction were used: (1) an evaluation of the effect of the
changes on the number of patients who left without being
seen; (2) a telephone survey immediately before and after
the process improvement changes using validated survey
questions; and (3) a comparison of the Picker Institute
Survey for University Health System Consortium (UHC)
benchmarks.2,3
Figure 6 documents the decline noted in the patients
who leave without being seen. Data were obtained from
the triage log for patients leaving before seeing the triage
nurse and from ED records of patients not responding
when called for room assignments. Over the implementa-
tion period, a 92% decline was noted in this patient popu-
lation.
Figure 1 lists the 6 questions from the telephone sur-
vey. Major improvements were noted in every category,
comparing July with April. Figures 7 and 8 show a sum-
mary of data for “poor” and “excellent” responses on a 5-
point scale for questions 1 to 3. The “definitely yes” and
“definitely no” answers on a 3-point scale, including “def-
initely no,” “probably yes,” and “definitely yes,” are
shown for questions 4 to 6.
The third method of identifying changes in patient sat-
isfaction used results from a comprehensive survey that
has been mailed annually toED patients for years. This
survey includes 54 questions that evaluate patient satisfac-
tion with a host of care-and service-related processes.2,3
The results are compiled into an overall rating of patient
satisfaction. More than 100 UHC hospitals use the Picker
Institute Survey, allowing comparisons and benchmark-
ing for hospitals in the consortium. Figure 9 shows the
results of the overall rating before (1997), during (second
quarter of 1998), and after (fourth quarter of 1998) imple-
mentation. The UHC benchmark (not average) is shown.
In 1997, we scored substantially below the benchmark.
During the quarter of implementation, substantial
improvement was noted, bringing results up to bench-
mark. After full implementation, a huge improvement
occurred, with the result well above the UHC benchmark.
It is notable that most of this improvement was caused by
an increase in the most satisfied (excellent) group.
I N T E R P R E T A T I O N A N D I M P L I C A T I O N S
During the data collection and analysis phase of the re-
design process, it became clear that many processes had
been developed on the basis of the needs of hospital per-
sonnel, departments, and operational realities. When
these processes were analyzed with a systematic step-wise
process improvement approach, their flaws were uncov-
ered. For example, including noncritical patients in zones
with critical patients delays care for the noncritical
patient. From a systems perspective this created a self-
Figure 4.
ED throughput interval.
4:33
4:21
4:04
3:36
2:55
2:38
2:09
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1998
Median time
3:07
Figure 5.
UC throughput interval.
2:24
1:55
1:40
1:26
1:12
0:57
0:43
0:28
0:14
0:00
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1998
Median time–
47% decrease
2:09
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kind and compassionate far more often. This was true
despite the fact that there was no specific intervention or
effort made to affect this issue. There was also marked
improvement in satisfaction with the care rendered, even
though there were no specific efforts to change actual
care.
Recent trends in defining quality in health care have
emphasized patient satisfaction. These trends have also
been reflected in the medical literature related to ED
patients.4-11 The fact that this effort, which was entirely
focused on service and process efficiency, led to improve-
ments in patient satisfaction and their perception of the
quality of care is an interesting corollary to the current
trend.
One of the most significant effects of the improved effi-
ciency was a marked decrease in the number of patients
who leave without being seen (Figure 6). The typical
patient who leaves an ED without being seen presents with
a relatively minor complaint and often waits a significant
defeating situation in which the patients who could be
cleared most quickly from the system, thereby freeing up
personnel, equipment, and space for additional patients,
often stayed the longest.
The success of the redesign process was most likely the
result of the multifaceted approach. Simply improving 1
or 2 of the process issues (eg, radiology or in-room regis-
tration) might have led to minimal overall improvement.
However, to affect waiting room and throughput intervals
by large amounts required improvements in all aspects of
intradepartmental and interdepartmental functioning.
Having the support of hospital administration and the
emergency physician staff was essential in getting over the
historical barriers of committing to rapidly assessing and
treating all patients.
In the patient satisfaction surveys, an interesting trend
was noted. Several questions that did not directly relate to
efficiency or timing dramatically improved. An example
was that, after the changes, the staff were perceived as
Table 2.
Theoretic and cost implications of process improvement changes in rank order of importance for decreasing waiting time intervals.
Theoretic
Basis for Full-Time
Rank Intervention Improvement Equivalent One Time/Start-Up Costs Ongoing Costs
1 Top institutional priority combined with Administrative change 1.0 MD Contract with college of medicine for 
physician-led departmental model full-time director
2 Change nursing ratios from 1 RN/5-6 Staffing change 11.2 RN Hiring-orientation Wages–benefits
rooms to 1 RN/4 rooms
3 Rapid triage and in-room registration Process change and 7.0 patient 6 computer dumb terminals and Wages–benefits
staffing change registration mobile carts: $2,000; terminal
coordinators data ports in each room: $3,000;
3 patient ID label printers: $1,200;
hiring-orientation
4 Radiology: changes in ordering, producing, Process change Radiograph film dry laser printer: No new cost compared with old 
printing, and making films available $40,000 process
for physicians
5 Radiology staffing for rapid availability Staffing change 4.2 radiology Hiring-orientation Wages–benefits
around the clock technologists
6 Unit clerical function: separating com- Process change and 4.2 UAs Computer workstation: $1,500 Wages–benefits
munication responsibilities from nursing staffing change
orders-laboratory-radiology processing
responsibilities
7 RN/patient-care technician admission Process change and 2.1 RN Hiring-orientation Wages–benefits
team staffing change 2.1 patient-care technicians
8 Electronic order entry Process change Training: $3,000
9 Create intermediate-severity nursing zone Process change
without monitored rooms
10 Laboratory ordering and process changes Process change FTE savings in laboratory: Bar-code printer: $500 Ongoing FTE savings in laboratory 
offset by change 8 specimen labels
11 Communication between triage, charge Process change 20 radios: $5,000 Radio maintenance and replacement: 
nurse, registration, nursing staff $1,000/y
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amount of time. When the wait becomes too long from the
patient’s perspective, they choose to seek medical care
elsewhere or not at all. Typically, this group represents
people who have become very angry and frustrated with
the inattention to their needs. The decrease in waiting
intervals was associated with a 92% decrease in patients
who leave without being seen.
A chronic problem for our institution has been the
unavailability of inpatient beds. Our institution has his-
torically had an inpatient census of more than 80%.
Because of this, the ED often functions as a holding unit
when inpatient beds are tight. However, we chose to
emphasize the fact that 80% to 85% of the patients that
present to our department are discharged. Thus, rather
than spending a major institutional effort to deal with
inpatient bed availability (an effort that has previously
failed many times), we chose to affect the waiting times of
patients over whom we had primary control. We were sur-
prised to find that the median throughput intervals for
admitted patients improved nearly as much (27%) as the
intervals for nonadmitted patients (31%). This occurred
despite the fact that the physician consultation-admission
team was unable to agree on recommendations for change
in admitting physician practices. The improvement in
throughput time for admitted patients appeared to be
related to 3 major changes: (1) the triage-to-patient-room
interval was significantly improved for both admitted and
nonadmitted patients; (2) decisionmaking related to inpa-
tient admission occurred earlier as a byproduct of faster
availability of diagnostic results and additional emergency
Figure 6.
Patients who left without being seen.
300
250
50
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1998
92% decrease
100
150
200
Jan 98
250
Dec 98
21
Figure7.
Telephone survey: “poor” responses.
70
60
50
40
30
20
10
0
Poor
wait
Poor
courtesy
Poor
overall
Poor
physician
wait
Poor
results
wait
Would
not
recommend
April
July
%
Figure 8.
Telephone survey: “excellent” responses.
80
70
60
50
40
20
10
0
Wait
time
April
July
30
Courtesy Overall
care
Physician
wait
Results
wait
Definitely
recommend
%
Figure 9.
Overall ED rating. 2Q98, Second quarter of 1998; 4Q98, fourth
quarter of 1998.
100
90
80
70
60
50
40
30
20
10
0
22.1
24.5
23.9
1997
31.2
24.3
20.2
2Q98
22.2
27.2
36.7
4Q98
23.5
25.6
26.1
UHC benchmark
Excellent
Very good
Good
E M E R G E N C Y D E P A R T M E N T R A P I D P R O C E S S R E D E S I G N
Spaite et al
1 7 6 A N N A L S O F E M E R G E N C Y M E D I C I N E 3 9 : 2 F E B R U A R Y 2 0 0 2
tionship between the physician director and the patient
care manager and their joint direct reporting to a vice
president has been particularly effective.
The ability to successfully implement these changes
elsewhere may be limited by the variations found among
EDs. However, we believe that many of the philosophic
and operational changes are relevant to most departments.
To aid in the potential for implementation elsewhere, we
refer the reader to the rank-order list in Table 2. This may
give some insight into the relative importance of each of
the interventions.
The reliance on handwritten times entered by nursing
staff for each of the times that were analyzed is a limita-
tion. Undoubtedly, there is some compromise of the accu-
racy of the times on the basis of variations in individual
timepieces in the department, as well as variation in
attention to accuracy among different personnel. How-
ever, we have no reason to believe that the times were sys-
tematically different in the before and after cohorts. The
decreases in patients who left without being seen, as well
as major improvements in patient satisfaction, make it
clear that the improvements could not have been phan-
tom changes based on time reporting alone.
It is also possible that some, or even all, of the improve-
ments noted in the department were caused by the Haw-
thorne effect. Hospital administration was more actively
involved in daily activities in the ED, often showing up
and discussing issues with the staff. More staff was added,
which improved staff attitude. Daily and weekly re-
minders about target ranges and successes kept the
progress in the forefront of the department’s operation.
Thus, some of the improvements could be related to the
focus of the organization rather than being caused solely
by the process changes themselves.
In summary, we report the results of a major effort to
decrease waiting time intervals and improve efficiency in
a university-based ED. As an institutional priority, and
with full integration of the emergency medicine faculty
into the process, major improvements were noted in
patient waiting and throughput intervals. This occurred
in the face of significant increases in patient volume.
We believe that these improvements are the result of
major administrative, philosophic, operational, and bud-
getary changes aimed at efficiency and patient satisfaction.
R E F E R E N C E S
1. Berwick DM, Espinosa J, Kosnik L. Reducing Waits and Delays and Improving Patient
Satisfaction in the Emergency Department. Boston, MA: Institute for Healthcare Improvement; 1999.
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physician coverage; and (3) an ED-based registered
nurse–patient-care technician admission team was imple-
mented that eased the workload for the admitting nurses
on the inpatient units.
The financial issues involved in this project are rele-
vant to any department that considers making sweeping
changes. Obviously, major financial investment was nec-
essary. However, a pleasant surprise has been that the
changes have more than paid for themselves. The ongoing
costs of this project have exceeded $1 million annually.
However, despite this major increase in cost, financial
analysis has shown that the department has gone from
being approximately $600,000 in the red to more than
$300,000 in the black after implementing these process
improvements. It is impossible to be sure that there is a
direct cause-and-effect relationship between these events.
However, this improvement of the bottom line was possi-
bly the result of 3 factors.
First, the marked decrease in throughput interval had
the net effect of adding rooms to the department. This
provided an increase in capacity to see new patients. In
fact, in the year after implementation, the volume (which
had reached a plateau at 49,000 for the 3 previous years)
increased by more than 17%.
Second, the improved efficiency allowed us to signifi-
cantly decrease the number of patients who leave without
being seen. These patients represented a recovery of lost
revenue.
Finally, the payer mix markedly improved. The cause of
this may be multifactorial. However, it appears that a
major factor in this improvement was related to the fact
that improved service and patient satisfaction encouraged
patients with a financial choice to drive past other EDs to
come to our facility. In fact, among all of the points of entry
to our hospital, the ED is now the site with the best payor
mix. This is very striking because before the changes, the
ED was the point of entry with the worst payor mix.
It has become clear to the hospital administration and
the emergency physicians that there are 2 foundational
prerequisites for success in an effort such as this. First,
there must be major commitment and support from the
highest levels of the hospital. The absence of this major
focus would doom an undertaking such as this to failure.
Second, integrating the emergency physicians and ED
administration by appointing a physician to have respon-
sibility and authority for all clinical operations provided a
level of coordination that had never been possible under
any other administrative model. This director has full
authority and responsibility for process, operations, per-
sonnel, and budgetary decisions. The collaborative rela-
E M E R G E N C Y D E P A R T M E N T R A P I D P R O C E S S R E D E S I G N
Spaite et al
F E B R U A R Y 2 0 0 2 3 9 : 2 A N N A L S O F E M E R G E N C Y M E D I C I N E 1 7 7
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