Carol Schmidt, RN, MHA, Vice President
Marcia Messer, RN, MBA, MHA, Project Manager, Critical Care Services
Anastasia Margos, MHA, Senior Financial Analyst
Vincent Taliano, MPA, Benchmarking Manager
Jennifer Biggs, RN, MS, Director, Medical-Surgical
Carol Clements, RN, Clinical Coordinator
Winnie Coburn, RN, BSN, ABQAUR/CPHQ, Director, Care Management
Margaret Edwards, RN, MSN, Director, Behavioral Health
Dianne Foster, RN, BSN, Director, Emergency Center/Cardiovascular Services
Lois Frasure, RN, BSN, MAOM, Manager, Clinical Resources
Patricia Hess, RN, ADN, Supervisor, Clinical Resources
Sharon Knutson, RN, MS, CPHQ, Manager, Clinical Decision Support
Diana McBroom, RN, MBA, Vice President, Patient Care Services, CNO
Herbert McReynolds, MD, Medical Director for Emergency Services
Cassie Pundt, RN, Manager, Emergency Center
Suzanne Swetman, MAM/HROB, MT (ASCP), Director, Laboratory Services

• Emergency Center (EC) length of stay by month
• Emergency Center volume
• Left without being seen (LWBS)
• EC satisfaction
• Ambulance volume

The changes listed below were a multidisciplinary team effort that varied from process changes to technological changes.

There are two noted variables, that did impact process changes and final outcomes, which are:

• Citywide no-divert (September 2004) pilot to address Emergency Center volume surges.
• New Emergency Center opened (April 2005) with phase I going from 34 to 43 patient care areas, and phase II (September 2005) to 51 patient care areas.

Changes:

• Developed an action plan with a multidisciplinary team with the goal to improve inpatient efficiency and throughput.
• Created a culture for in-house nursing units “pull system” versus “push system” as a concept to promote patient flow out of the Emergency Center (EC).
• Developed a centralized admitting process with an electronic tracking board.
• Implemented a bed control nurse position.
• Developed a Mobile Admission Team (WelcomeMAT) to do bedside admissions.
• Developed and implemented a process for Direct Admit admission labs to improve turnaround time.
• Developed and implemented a protocol to bypass the Emergency Center triage when there is a bed available.
• Adjusted triage staffing to volume peaks.
• Adjusted Emergency Center staffing to meet volume demand.
• Developed physician-driven triage protocols.
• Implemented bedside registration in the Emergency Center when patients bypass triage and/or arrive by ambulance.
• Refocused the inpatient unit Charge Nurse position to front-line operations with responsibility for unit flow and throughput.
• Utilized the Express Admission Unit as discharge lounge to open beds and improve patient flow when census is high.
• Standardized the channels of communication for follow-up with Primary Care Providers (PCPs) whose patients are cared for by the hospitalist through information systems interfacing.
• Provided portal access for physicians to obtain patient information readily.
• Opened Fast Track patient care area in the new Emergency Center to improve flow of the low acuity patients.
• Developed a focus team to decrease external and internal transportation delays.
• Standardized surgical admission and pre-admit testing process.
• Implemented processes to reduce operating room turnover time.
• Standardized recovery process between inpatients and outpatients.
• Developed balancing measures to ensure the changes made to improve patient flow did not adversely affect quality indicators.

This collaboratively initiative to improve hospital flow and increase access to care resulted in:

• Reducing the Emergency Center (EC) length of stay by 7 percent
• Increasing the EC monthly volume by 5 percent
• Increasing the inpatient daily census by 20 percent
• Improving the hospital net operating margin by 1.3 percent above budget

As indicated by the graphics, through applying changes in culture, processes, and technology, we were able to make a positive impact on ambulance volume, overall patient volume, and net operating margin. Through our balancing measures we noted there was no negative impact on patient satisfaction. To date we continue to work on maintaining gains while pursuing additional process improvements to improve our patients’ quality of care.

Lessons Learned:

• To recognize your full potential, prior to beginning such a project senior leadership must show 100 percent commitment and willingness to change so that they may foster the change.
• Leadership must ensure that the team members’ share the same perception of the change that is to occur, including roles, responsibilities, and what effects the change will have on the organization.
• Involving front-line associates and physicians from the very beginning promotes change acceptance. With involvement comes a feeling of belonging and ownership.
• Senior leadership communication of goals and the progression of the change to managers is key to a successful change effort.  Repeated and open COMMUNICATION using various avenues (i.e., all employee meetings, posters and bulletin boards, newsletters, emails, rounding on units) helps to decrease resistance and increase acceptance.
• Making changes, whether processes or cultural, takes time. Do not overwhelm associates with too many changes at one time or uncertainty, a feeling of loss of control, and resistance will follow.
• Resistance to change is to be expected, and leadership needs to provide the associates going through the change with resources to cope and support.

Patricia Hess, RN, ADN, Supervisor Clinical Resources
Carondelet St. Mary’s Hospital, a member of Ascension Health
phess@carondelet.org

[Storyboard presentation at IHI's National Forum, December 2005]