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Transforming Your Emergency Department

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Five transformation strategies to implement when patient flow is inefficient, outcome measures are falling and team culture is suffering.

When things aren’t going right in your hospital’s emergency department (ED), it’s tempting to point fingers or try to find a quick fix for the primary area of concern. But unless there’s truly only one issue at hand, a quick modification like a process change or adding staff may only treat the symptoms and not address the root cause of the problem. In fact, this approach may even create new challenges.

Larger problems may call for a more comprehensive solution: a total transformation of your emergency department.

This white paper explores what to do when patient flow is crawling, outcome measures are flagging and there’s bad blood among clinicians. It looks at strategies for achieving a true transformation of a hospital ED to enhance operations, culture, clinical care and the patient experience.

What is an ED Transformation?

As the term suggests, transforming an ED is a comprehensive solution for improving the way an ED functions. Unlike a rapid improvement or Kaizen event, which targets accelerated improvements in one care pathway, transformations are more globally oriented toward care pathways, processes, and stakeholders to fundamentally change the dynamics of an ED for the better.

Achieving that kind of fundamental change is a long-term proposition. It starts with the front-line team, literally everyone that touches the patient throughout their course of care. Engaging the C-suite executive sponsor is also important to align support services in support of departmental goals, provide data to view problems objectively, and to remove barriers to success. Designing and implementing strategies in these complex situations can be quite challenging; thus, total transformation can take months if not longer.

Some components of transformation are universal to all EDs. For example, all EDs benefit from examining their front-end processes for getting patients efficiently in the door and in front of a clinician, as well as their back-end processes for ensuring smooth handoffs with the hospital medicine department or facilitating discharges. All EDs, too, function better when they’ve aligned staffing to match patient demand by conducting a demand capacity analysis that forecasts patient volumes every hour of the week, even by season, and matches physician and nurse staffing to those levels.

However, the unique characteristics of each hospital, emergency department and patient population will dictate the specifics of how to approach each of these components of transformation. As you consider your own pathway to transformation, here are five overarching strategies to keep in mind:

1. Create a Guiding Coalition  

The first step on the path toward transformation is securing support and sponsorship from the hospital C-Suite. Support from the highest levels brings legitimacy and weight to the work, helping motivate clinicians and staff to engage with the transformation process.

Engagement throughout all levels of the ED, as well as ancillary service lines, is key. Though the ED is the “front door” of the hospital, its operation is influenced by factors outside of the ED – such as how quickly the lab can return test results, radiology turnaround times, and how long it takes for the hospital medicine team to respond to a request for admission. These and any other relevant stakeholders must be informed of the ED transformation effort, and its C-suite support, and enlisted to do their part toward the department’s larger goals. Aligning all of these stakeholders increases the likelihood of a successful transformation.

2. Adopt a Team Mindset 

In order for transformation efforts to be effective and lasting, there must be a collective sense of ownership and commitment to improvement. Everyone – from physicians and nurses to technicians and staff – must adopt a mindset that all parties are working as a team to deliver better care for patients. Keeping a focus on clinical quality, and the broader goal that all efforts are driving toward a better experience and better outcome for patients, helps keep all stakeholders engaged and moving in the right direction. When your team is meeting to design strategies, it is important that all team members’ opinions carry equal weight in the war room. There is no better way to sabotage a great team effort than to pull rank and boss people around – respect others and they will do their best work and you will get your best outcome.

3. Build Quick Wins into the Transformation

Looking at the big picture of transformation can be daunting for ED leaders and clinicians. Tackling issues that show immediate improvement is a good way to engage all members of the ED team and build momentum toward even greater achievements in the long-term.

For example, EDs facing challenges with patient flow can often institute changes to expedite care and discharge for those with an Emergency Severity Index (ESI) level of 4 or 5 – patients who are stable with less urgent or non-urgent needs, such as those requiring only sutures or oral medications. Instead of letting these patients wait for open beds while treating those with more immediate needs, EDs may be able to dedicate a few beds or create a vertical treatment area for ESI 4s and 5s so they can flow through the department faster. Not only is this good for flow, but it’s good for patient experience, financials and risk management as well. Optimizing flow in lower acuity patient streams is usually quicker and easier and can build momentum for the more difficult mid- and high-acuity patient streams.

Sharp Grossmont Hospital’s ED which treats about 100,000 patients annually, instituted this type of split-flow model. Six months after doing so, the California facility reduced length of stay among low-acuity patients by 62% (from 410 to 156 minutes) and reduced left without treatment (LWOT) percentage from 4.45% to just eight-tenths of a percent. The dramatic improvements gave a boost to morale and clinician communication as they continued on an improvement process.

4. Gather Objective Data 

Deming once said, “Without data, you are just another person with an opinion.” To achieve and show improvement, EDs must be able to measure performance – both the baseline from which they’re starting and the progress along the way – to show the impact of their efforts. When establishing metrics, it’s critical that all stakeholders are honest and forthcoming with objective data that allows for honest measurement going forward. With objective baseline data in hand, you can begin to properly align goals, set strategies and implement tactics to achieve desired results.

For example, the ED will likely want to examine radiology turnaround times as part of its length of stay measurement. Often, the lab will report turn-around times of 15-20 minutes on a complete blood count or 40 minutes on a troponin, exceeding the goals of the organization. However, it is common for labs to report specimen receipt to result, omitting the entire collect-to-receipt interval which is usually the longest and most variable. Without agreeing on the appropriate measures, you may miss the most significant elements needing improvement.

5. Engage a Partner 

For many emergency departments, engaging with a partner experienced in ED transformation makes all the difference in designing and keeping transformation efforts on track. A third-party who can show results from successful transformation engagements brings the insights of past efforts to your unique situation – helping you see challenges and opportunities in new ways and make the right choices for the long-term benefit of your ED.

Remember: It’s a Process 

Fully transforming an emergency department takes time, and it’s important for all stakeholders to understand and accept there will be a beginning, a middle and an end that won’t come overnight (continuous improvement never ends). Some EDs find it helpful to adopt a structured project management schedule to keep key team members informed of progress and on task in striving toward outlined goals. That structure could come in the form of weekly or bi-weekly meetings where the team works through a project list of individual performance improvement initiatives that, together, bring the ED along the path toward transformation.


Transforming an ED takes time, commitment and teamwork among many stakeholders. But when executed properly, it can result in the comprehensive improvement of the department’s operations, clinical care and culture.



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