Consumer Sentiment Ignites Positive Change for Yuma Regional Medical Center’s ED

Added on Jan 9, 2020

comment bubblesConsumer Sentiment Ignites Positive Change for Yuma Regional Medical Center's ED
By Audrey Doyle

In January 2016, emergency department leaders at Yuma Regional Medical Center in Yuma, Arizona, had a reputational crisis on their hands.

A seven-hour average length of stay (LOS) and poor provider engagement had led to scathing comments from patients on the EDCAHPS survey, social media, and review websites. Backing their sentiments were an overall mean score of 69% and a 1st percentile ranking on the ED’s initial Press Ganey Emergency Department Survey.

Three years later, at the peak of its busy season and despite a 15% increase in the number of patients being served, the ED had cut its average LOS by 50%, raised its overall mean score to 87%, and raised its ranking to the 49th percentile. In addition, it had dropped its LWBS rate—a measurement EDs use to designate a patient encounter that ended with the patient leaving without being seen by a physician—from 10% to less than 2%. And patients’ cringeworthy reviews were replaced by glowing comments about short wait times, exceptional care, and friendly, engaged staff.

Although the department had moved from a 36,000-square-foot, 41-bed space to a new 58,000-square-foot, 72-bed space in December 2016, “that’s not what made the difference,” said Erin Brandt, the facility’s director of patient experience and care advocacy. Rather, Brandt and Breanna Caraway, RN, administrative director of the ED, attribute the performance turnaround to a multiyear transformation that involved understanding the top opportunities for improvement, listening to the patient voice, and implementing changes that address patient experience, employee engagement, and process design.

Identifying Existing Bottlenecks

Yuma Regional Medical Center (YRMC) is a 406-bed community hospital staffed by 2,400 employees, more than 500 medical practitioners, and hundreds of volunteers. ED leaders realized they needed a  sustainable improvement plan in 2015, when a significant increase in patient volume caused the staff to struggle with throughput. The transition to the new ED was less than a year away, and leaders were convinced that a change in process, coupled with a new space nearly double the size of the existing space, would enable them to meet the community’s needs. So they launched a process improvement strategy in early 2016 to locate the bottlenecks in the existing ED and eliminate them before moving to the new ED.

As part of the strategy, a team comprising department leaders, physicians, nurses, lab and X-ray technicians, and nonclinical staff conducted a three-day kaizen event in which they were instructed to “walk a mile in the shoes of an ED patient,” according to Caraway, and report back to one another their observations of the patient’s journey from arrival to disposition. From those observations, the team created a value stream map to understand where improvements were necessary.

The value stream map was eye-opening, according to Caraway. “We were sending patients back to the waiting room after they registered, and again after they were triaged, and then again after they met with the medical screener or provider,” said Caraway. This resulted in a patient journey that was filled with non-value-added wait time and that forced patients to move around a lot when they weren’t feeling well. “Although the process worked for us, it wasn’t until we viewed it from the patient’s perspective that we saw it wasn’t working for them,” she said.

To fix the problem, the team developed a new front-end process and began implementing it while they were in the old ED. In the new process, the patient registers, and then meets with the medical screener/provider and triage nurse simultaneously, either at the bedside if a bed is available or in the triage area if not. The screener/provider examines the patient, orders any necessary diagnostic tests, and reviews and discusses the results with the patient. Then the patient is admitted to the hospital or discharged.

The team also developed a standard set of protocols and order sets for the intake process. “All of these changes shaved time off the front-end process, and it worked well,” Caraway said. Although the team knew from the value stream map that the back-end process—the time from review and discussion of test results to patient disposition—also caused issues with wait times, they were optimistic that the additional space in the new ED, coupled with the front-end changes, would be enough to give them the results they were hoping for.

The staff were optimistic too, according to Brandt. To nurture that optimism, as well as generate excitement about the new ED among the community, the hospital launched a months-long marketing campaign that included interviews with the press and reports explaining how the new space would have a positive impact on patient care. The hospital also held a grand opening celebration in the new ED a few weeks before the transition was complete. Attended by hundreds of employees and community members, the event even included a Teddy Bear Clinic in which nearly 1,000 children in the community received a teddy bear and participated in a mock intake process.

The enthusiasm for the impending transition to the new space was palpable, according to Brandt; extremely high expectations had been set, and the staff were excited and hopeful. As the community sensed the staff’s excitement, the ED’s online ratings and patient comments started to improve.

That improvement was short-lived, however. A few weeks after the new ED opened, patients who received care there started speaking up about their experience. What they said was difficult for leadership and staff to hear, as patients continued to express extreme frustration regarding hours-long wait times, poorly engaged care providers, and negative care experiences overall.

According to Caraway, it was clear that more space and a streamlined front-end process weren’t compensating for lengthy patient disposition times. So, at the beginning of 2018, the team conducted another kaizen event to identify areas for improvement on the back end. They also set their future-state goals—namely, that a patient’s LOS should be no more than 240 minutes (four hours), and that they had to be 80% successful in achieving that goal. They also set goals for implementation of orders and time to patient disposition. Then they developed several improvement strategies.

Implementing Improvement Strategies

One strategy was to introduce a new departmental layout in which the ED was divided into three large pods, each containing 10- or 11-bed mini pods that are staffed with a physician, a nurse team leader, two primary care nurses, and a patient care technician. Each pod has a color-coded tracking board into which the ED’s electronic medical record system feeds patient data. As patients progress through their ED journey, their corresponding spot on the board changes color to let the team know whether they’re on track or in danger of missing a target. “For example, our door-to-doc time is 30 minutes. If the tracker shows yellow, it means 15 minutes have passed and we have only 15 more minutes to get the doctor in there to see the patient,” said Caraway.

The team also began conducting daily morning huddles with the hospital’s CMO, CEO, and CNO to discuss the previous day’s successes and any barriers to success they anticipate for the current day. In addition, they developed a standard list of supplies for each exam room’s supply cart, and they put together a “mother cart” from which each supply cart is restocked so that staff don’t have to visit the hospital’s central supply room to retrieve a missing supply. “This saves time and is great from a budget standpoint because our department only orders what we need,” Caraway said.

To gain a better understanding of patients’ grievances, Brandt and her team began trending all patient comments, and if a grievance concerns staff–patient interaction, the staff member now receives communication training. Caraway also now calls every patient who has negatively commented about their experience in a survey or online. “I listen, apologize, thank them for the courage to tell us how they felt, and let them know their comments are important to us, we’re committed to improvement, and their feedback will help us succeed,” she said. Patients who made positive comments receive a thank-you call from patient advocacy team volunteers.

Trending patient comments and speaking with patients about their experience has been a gamechanger, Brandt said, adding that in 2019, the department received half the number of complaints and grievances it received in 2018. In addition, according to Caraway, in 2019, with 86,000 patient visits, the ED had an average LOS of 220 minutes and a success rate of 73%. And thanks to the more efficient patient disposition process, at peak hours of the day no more than 56 of the ED’s 72 beds were occupied.

As a result of these strategies, patients’ perceptions of their care experience have improved remarkably, as has the tenor of their comments, which now typically cite lengths of stay of only one to two hours and describe care providers as friendly, caring, and pleasant.

Although Caraway and Brandt emphasize that their journey is far from complete, they’re proud of what the ED achieved and are mindful of the lessons they learned. “More space is nice, but it wasn’t the solution to problems with efficiency,” Brandt said.

“We learned so much from our patients—from seeing their journey through their eyes and listening to what they said about us, even when it hurt,” Caraway concluded. “By keeping the volume on the patient voice turned up, we’ll continue to make the ED experience the best it can be.”