Why It Matters
Long waits, poor patient satisfaction, and backlogs are not inevitable parts of the ED experience. A safety net system improved flow while handling double-digit growth in patient volume.
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3 Myths about Improving Flow in the Emergency Department

By Assaad Sayah | Wednesday, October 12, 2016

Three Myths about Improving Flow in the Emergency Department
At Cambridge Health Alliance, empty waiting rooms are a sign of improvements in emergency department flow.

The scene in the emergency department (ED) waiting room is all too familiar. Infants crying in the arms of worried parents. Kids sniffling, coughing, or wheezing. Adults in distress, hoping they’re not sitting too close to someone who might be contagious. Rows of people who would rather be anywhere else, but they’re in the ED because they’re in crisis.

And, unless they’re in need of life or death care, they all end up waiting for hours.

What if I told you it doesn’t have to be this way? Long waits, poor patient satisfaction, and perpetual backlogs are not inevitable parts of the ED experience.

At Cambridge Health Alliance (CHA), where I work as chief medical officer, we’ve struggled with ED operations for years. Now, after making our care more patient-centered and efficient, we’ve seen significant changes: decreased door-to-provider times, shorter durations of stay, fewer patients leaving without being seen, and increased patient satisfaction. All that at a safety net organization that sees 40,000-50,000 ED patients a year.

To explain how we made these important strides, I’ll debunk some of the common misconceptions about ED flow.

Myth #1: The only way to improve flow is through physical expansion.

Many people assume you need to build your way out of ED flow problems. Ironically, after our ED expansion, CHA saw negative trends in our patient satisfaction scores, door-to-provider time, and duration of stay.

It wasn’t until we launched an improvement project to streamline processes and optimize patient flow that we started to see positive changes in our data. Instead of designing a physical solution to a process problem, we focused on reengineering a pivotal moment in the ED experience: the patient’s arrival. Two important components of this included:

  • Simplified initial registration — To help patients see a clinician as soon as possible, we pared our initial registration down to the bare minimum. Staff members ask three questions: name, social security number or date of birth, and chief complaint. Between tests and procedures, staff complete bedside registration after providers assess and stabilize the patient.
  • Rapid Assessment Unit (RAU) — We created an RAU without physical expansion. We instead combined the areas previously occupied by registration, triage, and “express care.” This allows assessment and treatment at the point of entry to the ED. After triage, low-acuity patients receive all their care in the RAU without ever having to enter the acute ED area. We immediately move patients with higher acuity to the acute ED area to receive evaluation and treatment.

Myth #2: You can’t improve flow without hiring new staff.

Instead of adding new FTEs to our payroll, we capitalized on the customer service experience of our non-clinical multilingual greeters and receptionists. We trained them to be “Patient Partners.” Patient Partners welcome patients, conduct the initial mini-registration, record the basic data in the electronic medical record, and accompany the patients immediately to the Rapid Assessment Unit.

We also improved flow without hiring new clinical personnel. The same group of nurses and physician assistants that covered triage and express care now staff the RAU. We managed this by viewing our challenges as process issues. We studied the ED workflow to root out inefficiencies, and found many gaps and overlaps in staff responsibilities. Subsequently, we defined and clarified the roles of all ED personnel, eliminated redundancies, and improved communication.

Such streamlining can sometimes lead to overburdening staff. In our case, however, we found that by shortening patient cycle time by almost half, we were able to create more capacity in space and personnel. The result: we handled more volume, sustained our outcomes, and made the work feel easier.

Myth #3: Hospitals serving the most vulnerable populations can’t improve flow because they lack resources.

This widespread assumption too often goes unchallenged. Consequently, patients and staff wait years for change, too often with no hope of relief.

We don’t have to accept the status quo. Transformation of the ED is challenging, but it can also enhance the patient experience, and be manageable, inexpensive, and sustainable. CHA’s operational changes have significantly increased efficiency without major capital investment. We have sustained our improvements for more than seven years while handling double-digit growth in patient volume.

As a safety net organization, CHA has to be creative and efficient. But in the current health care environment, can any organization afford to waste resources?

Assaad Sayah, MD, is Chief Medical Officer, Senior Vice President Primary & Emergency Services at Cambridge Health Alliance. He is also faculty for IHI's Hospital Flow Professional Development Program, running May 6–10, 2019, Boston, MA.

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