Putting ‘Express’ Back in Hospital’s ED Express Care

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y Ben Miles and Charles DeBusk

"Emergency rooms in Metro Detroit and in many regions across the country are dangerously crowded...," chronicled an article in The Detroit News in the fall of 2004. St. John Health, a six-hospital system in Detroit (USA), was well aware of the problem. It had been feeling the pressure of long patient waiting times in its emergency departments for years. "We've been solving this problem for 25 years" was a common sentiment expressed by emergency department (ED) leadership. But by the time the newspaper article came out, the hospital system had already realized a new approach was needed and had begun addressing the throughput issue using Six Sigma and Lean. At Providence Hospital, part of the St. John Health system, waiting times to see physicians ranged from 11 minutes to 4 hours. With the Providence ED seeing more 60,000 patients on an annual basis, the opportunity for improvement was enormous. 

Characterizing the Problem

Initially, customer input or voice of the customer caused Providence to set the upper specification limit for patients to be seen in the ED at 60 minutes. The current process averaged 64 minutes, but with a 39-minute standard deviation. This resulted in only 67 percent of the patients being seen within the 60-minute specification, and that was unacceptable to the hospital. With its first project, the Lean Six Sigma team set a goal to raise the number of patients seen within 60 minutes to 80 percent.

Findings from the Six Sigma Analyze phase indicated waiting times were longer when there was a lack of bed availability in the ED, patients needed X-rays and when the census was high. To its surprise, the team also found that lower acuity patients, who were treated in express care, also waited longer to see a physician. The team had assumed that express care was more of an "express" process. Using historical design of experiments, the team determined that 94 percent of the variation in waiting to see a physician was driven by:

• Bed availability
• Radiology
• Express care

Developing a Solution

Given the size and complexity of bed availability, that issue was scheduled to be addressed in a subsequent wave, with separate inpatient and outpatient projects.

The radiology issue was approached by conducting a Work-Out on X-ray turnaround time for emergency patients. Key stakeholders from radiology and the emergency department participated, and some quick solutions were identified and implemented. For example, data demonstrated that during peak times (Monday-Friday, between 4 and 7 p.m.), the X-ray turnaround time was significantly longer than at other times. It was discovered that the two X-ray rooms in the ED were consistently underutilized due to staffing issues. In order to facilitate turnaround time, radiology leadership recruited two radiology technicians to cover these key times. Also, radiologist coverage was added. Larger-scope issues were tabled and are now the focus of a Six Sigma project recently started.

Of the three critical areas identified in the Analyze phase, express care showed the greatest potential for meaningful change with the least amount of difficulty. This became apparent with the use of a tool called the priority/payoff matrix. Since express care was under the control of the emergency department leadership, the lion's share of improvement for this initial project came from this area. Data analysis showed that it took nearly twice as long to see a physician in express care as it did in the balance of the department.

Examining Patient Flow Problems

Lean strategies were identified as being the tools of choice for improvement. The core Six Sigma team and select individuals from operations (such as an IT representative and an environmental services worker) were pulled together for a mini-Kaizen event. With basic data already collected and many flow problems identified in the Six Sigma project, the team met for four hours rather than the typical five-day event.

Team members physically walked the path of the patient from quick registration to express care. Where possible, supplies and workstations were moved immediately in order to facilitate the flow of the patient. Red tags were used for changes that could not be immediately addressed. These changes were accomplished within 24 hours. Most of the changes took place within the express care area itself, with a number of changes to and behind the nurse station. During the event, the counter behind the nurse station was raised by eight inches in order to move a small refrigerator containing medication under the counter and still behind the station, thereby adhering to regulations. Also, the station itself was rearranged. IT utilized the newly created space to install a registrar workstation with portable capability. This enabled bedside registration which improved express care throughput by 25 minutes. This registrar is dedicated solely to express care, which was a redeployment of staffing within the department.

An "aha" moment for the team was the discovery of fax machine problems. Antiquated fax machines in express care (as well as the chest pain unit) were identified as barriers to communication. In retrospect, this seemed like it should have been an obvious problem to fix. But the staff had learned to work around these everyday problems for so long, they no longer consciously recognized them as barriers. The mini-Kaizen helped the staff to recognize the delays and customer satisfaction issues caused by these problems and empowered them to make changes. With this empowerment, the staff began to view quality as part of all they do.

By making these improvements, the overall throughput of the express care department improved from 3.49 hours to 2.55 hours.
 
Another goal of the hospital was to reduce the leave-without-being-seen rate from 2.4 to below 1 percent. As of December 2004, the rate was down to 1.2 percent. With roughly 60,000 visits per year, this has translated into an opportunity of 720 outpatient visits that would have been lost, as well as an estimated 175 admissions.

Summary: Pleasing Patients and Staff

The express care mini-Kaizen, and Work-Out on radiology turnaround times yielded remarkable results in patient waiting times and ED throughput. Specific results can be seen in the table below, showing patient waiting times before and after the project and the percentage improvement.

Table 1: Patient Waiting Time (From When Patient Enters ED Until Seen by a Physician)
	Baseline	Control Phase	% Improvement
Mean Waiting Time	64 minutes	40 minutes	38%
Waiting Time Standard Deviation	45 minutes	28 minutes	38%
Percent of Patients Seen Within 60 Minutes	67%	83%	24%

In addition to the improvement in waiting times, a substantial improvement has been made in the overall length of stay (LOS) within the department. When comparing the throughput time from before and after the improvements, an average of 53 minutes has been reduced from LOS for ED patients. This represents an opportunity to see approximately 18 percent more patients.

The financial benefit of the increased ED throughput and the reduced number of patients leaving without being seen was calculated to be in excess of $1.2 million.

While the numeric changes in waiting time indicate the current process improvement, the long-term climate for change is indicated by the views and stories of the staff. These stories have been universally centered on how they have been empowered to make change in their department, which has led to increased accountability and satisfaction. The formal and informal response from staff associates, as well as physicians, has been overwhelmingly positive while at the same time the staff is caring for more patients with an improved throughput.

"The change has been profound on my initial contact with the patient," said Dr. Steven McGraw, ED physician. "Instead of apologizing for the delay in greeting a patient and defusing his/her frustrations, I can now more readily move ahead with treatment." Dr. Martin Harris, chief of emergency medicine, noted: "I've found this entire experience to be both personally and professionally rewarding…. Six Sigma has introduced a business discipline to the way we manage our resources to be the functional front door to the hospital."

About the Authors: Ben Miles is a Black Belt with St. John Health. He has seven years of healthcare finance experience and has earned degrees in corporate finance and management (MBA). He has been trained as a Baldrige examiner and is a member of the American Society for Quality and Institute of Industrial Engineers. He can be reached at benjamin.miles@stjohn.org. Charles DeBusk is a GE-certified Six Sigma Master Black Belt and senior consultant for Performance Solutions at GE Healthcare. He has a master's degree in industrial engineering from the University of Tennessee (USA). Mr. DeBusk also is a member of the American Society for Quality and a registered professional engineer. He can be reached at charles.debusk@med.ge.com.

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