VA Boston Healthcare System
West Roxbury, Massachusetts, USA
The VA Boston Healthcare System team is a participant in the IHI Learning and Innovation Community on Improving Flow Through Acute Care Settings.
Joan Clifford, RN, Deputy Nurse Executive (Team Sponsor)
Stephan Gaehde, MD, Medical Director, Emergency Department
John Marinello, RN, Nurse Manager, Emergency
All Emergency Department Staff
Margaret Andrews, Patient Services Supervisor
Cathy Stephens, Chief of Patient Services
To redesign a system for the emergency department (ED) to improve timeliness and reduce delays by:
- Reducing the overall cycle time to admit/transfer patient to less than 1 hour
- Reducing the number of patients who left without being seen to less than 3 percent
- Reducing or eliminating the number of hours for ED diversion
- Improving communication between shifts and among staff (physicians and nurses)
- Improving overall teamwork
The overall aim of our flow journey is to increase access to inpatient tertiary services for the veterans in our integrated network. The Veterans Health Administration (VHA) has set performance targets for some of our measures at both a fully satisfactory and an exceptional level. Our goal is to be at or above the exceptional level for those targets.
- Percent of Patients Who Left Without Being Seen
[Exceptional = Less than 3 percent of the patients left prematurely during the quarter]
- Percent of Patients with ED Stays of Greater Than 6 Hours
[Exceptional = Less than 5 percent of all ED stays exceed 6 hours in length]
- Emergency Department Average Length of Stay (LOS)
[Goal = 3 hours or less]
- Decision to Admit to Inpatient Unit Median Time (in Minutes)
[Goal = Less than 1 hour]
- Number of ED Diversion Hours
[Goal = No diversion hours]
Summary of Results / Lessons Learned / Next Steps
- A systems approach to managing flow for VA Boston Healthcare System has allowed us to increase the throughput of the ED, meeting our goal of increasing access to our tertiary services. We have much more to do but we are heading in the right direction. It really is a journey that keeps taking us towards a better place.
- A systems approach to solving flow problems is an absolute necessity. Our teams have come to realize the interconnectedness of units and the need to pay attention to the upstream and downstream effects of changes (i.e., changes in one area and the effect it may have on another).
- Involving those at the front line is essential. As issues were identified by the ED Flow Team, they invited those who work in other areas to be part of the solution ― one way to get the buy-in!
Although the median cycle time for admitting to inpatient beds is above the goal, delay at certain times (2:00 PM to 5:00 PM) has been identified as an area that needs improvement. This has also been identified as an area of focus for the Inpatient Flow Team, and a group representing inpatient areas and the ED will be flow mapping the processes in those areas and working on some tests of change. Their focus will be to reduce admission delays to less than one hour.