Creating a More Efficient ED at Meadows Regional Medical Center

Added on Mar 9, 2020

emergency-department-ambulanceCreating a More Efficient Emergency Department at Meadows Regional Medical Center
By Lauren Keeley

Back in the 1970s, when Alan Kent was an emergency department clerk, EDs typically weren’t well-integrated with the hospitals to which they were connected. Rather, they functioned as standalone departments providing episodic care primarily to acute cases.

Today Kent is president and CEO of Meadows Regional Medical Center in Vidalia, Georgia, and he sees his organization’s ED as intrinsically connected and central to the rest of the hospital and the community.

“The ED is the front door to a health system,” Kent stated during a recent webinar in which he discussed strategies and tactics Meadows leaders implemented to improve the care experience in their ED. When an ED patient is admitted to the hospital, their care experience in the ED can significantly impact their perception of their experience as an inpatient, which, in turn, can affect the overall rating they give the hospital. “Therefore, that first impression is very powerful,” Kent said. “A rapid response and compassionate touch will set the tone for the visit.”

In addition to delivering emergency care and serving as the gateway to inpatient care, EDs act as key safety net providers in many communities today, offering primary and specialty care to those who can’t get treatment in other settings. Even with the growing number of urgent care facilities across the country, EDs are the default option when primary care is closed.

According to Kent, Meadows Regional Medical Center is the only nationally accredited hospital in Montgomery, Toombs, Treutien, and Tattnall counties, serving 82,000 to 100,000 patients who have limited access to care, making the Meadows ED a particularly crucial community resource for the rural population of Vidalia. So, when the ED patient volume began to escalate, leaders realized they needed to be more efficient in order to meet the increased demand without additional resources and without compromising care quality or the safety of patients and staff.

Together with Press Ganey consultants, Meadows leaders analyzed the ED’s operations to identify gaps in care delivery and pinpoint opportunities for improvement. Aware that 67% of inpatient admissions at Meadows originate in the ED, the team determined that they needed to tailor improvements to address the connectivity with the inpatient and ambulatory settings while supporting staff on the journey to becoming a high reliability, patient-centric organization, which is the health system’s overarching objective, according to Adam Higman, a partner with Press Ganey Strategic Consulting.

The analysis also revealed that the ED was performing below industry benchmarks on certain key measures, including wait time, visit length, and left without being seen (LWBS) rate. Further, the facility’s patient experience scores were in the bottom quartile, and its fragmented and inefficient staffing model didn’t support patient flow in high-volume periods.

Through a series of improvement strategies addressing leadership, staffing and operations, care transitions, optimal allocation of physical space, and patient experience, Meadows increased its levels of employee and physician engagement, reduced its LWBS rate by 3% (equating to millions of dollars in additional revenue), and significantly improved its patient experience scores. Specifically, the hospital’s rank for Likelihood to Recommend rose from the 43rd to the 51st percentile, while Communication with Nurses increased from the 30th to the 65th percentile, Communication with Doctors rose from the 44th to the 84th percentile, Communication about Pain rose from the 32nd to the 75th percentile, and Care Transitions increased from the 18th to the 49th percentile.

Adjusting Staffing Models to Meet Care Needs

As noted, the analysis pointed to a need for a more efficient staffing model that matched resources to workload. According to Kent, the issue was not staffing levels; it was staff allocation. “Our staffing indicators showed an appropriate level of staffing, but there was still a high level of turnover and employee dissatisfaction,” Kent said. Because of this, the team always felt like they were working short, he said.

To remedy this, the team redefined the roles and responsibilities of the staff, shifted schedules, and reallocated resources. For example, they implemented an earlier mid-shift arrival ahead of the volume curve and increased staff on higher-volume days of the week. To streamline direct discharge, they included an additional RN in triage and more clerical support during peak volume periods.

Another area of weakness identified by the analysis was a lack of operational support for the then newly promoted nurse leader. Although she had the potential skills, experience, and credentials to be successful in her new role, she didn’t have the experience to re-envision the department while responding to competing demands from patients, staff, and physicians. To address this, the team refocused the nurse manager role to be more strategic and programmatic and took away direct patient care responsibilities. She was now able to focus on managing patient flow, supporting the team, leading huddles, and developing mid-level nurses to ensure that patients didn’t fall through the cracks.

The ED also implemented a leader education and mentoring program for the charge nurses and the nurse manager, and periodic on-site check-ins over six months to ingrain the new skillsets.

Underlying these initiatives was an emphasis on standardizing work wherever possible, from huddles to handoffs. “We wanted to be as inclusive as possible in our improvement efforts, standardizing work and integrating everyone into the culture,” said Kent. “This meant training our leaders to be bridge builders across departments.”

The physical design of the ED also presented efficiency challenges. Its traditional layout inhibited communication between the registration and clinical staff and led to many rooms not being used in a manner appropriate to service, Kent recalled. Although renovating the space was out of the question, there were ways to redesign the layout to better meet volume demands and facilitate flow.

“We decided to focus on building systems and processes into the workflow to help accommodate what isn’t ideal in terms of the environment,” said Higman.

For example, dividing the triage room into two bays and creating a visualization of the waiting room prevented a bottleneck at registration. The team also annexed additional bed space from an adjacent area and repurposed it into a fast-track area.

The operational assessment also revealed care management issues that needed to be addressed. For example, the improvement team looked at how limited formalized care management was affecting the continuum of care. Handoffs between the ED and inpatient areas were fragmented, causing delays in patient movement and creating opportunities for safety events. There were also inconsistencies in mechanisms to promote self-management post-discharge, such as follow-up phone calls and an appointment scheduling process.

To enhance the efficiency of care transitions, the improvement team reviewed patient-level data to better understand patterns across the patient population. At the time of the initial assessment, patients with a history of five or more ED visits in one year made up 3% of the population but 31% of the ED volume. One patient utilized the ED 68 times in one year. In light of this statistic, Meadows leaders developed an identification, management, and review process for ED super-utilizers and implemented a series of ambulatory follow-up procedures for discharged ED patients.

Bridging Operational Silos

In addition to the negative influence on patient experience performance, the various process inefficiencies were symptoms of a larger issue that needed to be addressed: a silo-based culture. Like many health systems, departments and management groups across the hospital were not structured to share information, goals, tools, priorities, and processes with other departments. This scenario is especially challenging to ED efficiency, which rests heavily on interaction with teams in multiple areas. For this reason, the improvement team sought to enhance cross-functional communication. One of the most significant changes they made was creating joint patient-centric projects and measurements to promote relationships, communication, and common patient-centered goals between the ED staff, providers, registration, and the lab. In short, they engaged all staff around the patient.

“ED improvement is a give-and-take. If we are asking staff to improve the way they communicate with patients—to convey empathy, to make a connection—then as leaders we must make a commitment to solving some of the daily headaches and process issues that hinder this ability,” explained Higman. “It’s a cooperative effort.”

Since the start of its journey, Meadows’ patient experience scores have been on the uptick, and its LWBS rate has dropped from 4% to 1%. Although the improvements have had a huge impact, the journey is ongoing, Kent stressed, noting that there are still opportunities for progress, such as improving the discharge information process and ED throughput time.

“There will always be pressures on the ED, but these analyses and focus points have put us on the right track to a level of improvement that is systemwide and sustainable. It has definitely been worth the effort,” Kent said.