​Memorial Regional Hospital
Hollywood, Florida, USA

Team

Memorial Regional Hospital is a participant in IHI’s Learning and Innovation Community on Operational and Clinical Improvement in the Emergency Department.

• Mel Stibal, Administrative Director, ED/Trauma
• Jennifer Reilly-Miller, Director, ED
• Maria Wojoknowksi, ED Clinical Manger
• Stacey Silverman, ED Clinical Manager
• Stacy Caschette, ED Clinical Manager
• Errol Charles, ED Clinical Manager
• Jennifer Dunn, ED Clinician
• Dr. Randy Katz, Associate Medical Director, ED
• Dr. Fred Keroff, Medical Director, ED
• Debbie Tedder, COO/CNO (Team Sponsor)

Aim

Improve care and service in the adult emergency department (ED) by focusing on key operational, clinical, and service improvement strategies that will result by January 2008 in:

• 25 percent reduction in treated and released length of stay (LOS) [Goal: 210 minutes]
• 25 percent reduction in admission LOS [Goal: 270 minutes]
• Reduce rate of patients who left without treatment (LWOT) to below 2 percent 
• Be at top deciles of CMS/HQI measures associated with community-acquired pneumonia (CAP)
• Be at top deciles of CMS/HQI measures associated with acute myocardial infarction (AMI)
• Patient satisfaction greater than 75 percent

Measures

Changes

The Memorial Regional Multidisciplinary ED Team began many of their changes in 2004 and initially focused on building the right team to be able to drive improvement from a human resources perspective (i.e., having the right people on the team). These changes included:

• Formal/informal leaders without appropriate skill set taken out of charge and replaced; instituted Charge Nurse Course
• Staff held accountable for actions
• Leadership held accountable for outcomes
• Developed behavioral expectations for all staff; they were tied to performance review

• Daily shift gatherings
• Putting the patient at the center of the equation
• Formulating teams for specific measures
• Bi-monthly accountability meetings for ED leadership team
• Weekly updates/graphs for staff; displayed in public areas
• Effective communication to staff of the fact that initiatives were going to make their lives better

• Patient service representative
  • Rounding
  • Focus on hallway and treat-and-release patients
• Call backs
  • Retired nurses
  • Staff relief
• Bedside report
  • Just like the old days
• Leader rounding
  • Executive
  • ED leadership
  • Middle management
  • Documentation
• Use of StuderGroup principles, including structured patient interaction formats (for example, AIDET: Acknowledge-Introduce-Duration-Explanation-Thank You)
• 30/60/90-day designs
  • Timeframes for quality improvement cycles established to convey to staff the expectations for pacing
  • Meetings at 30/60/90-day intervals to review progress

• Plan Capacity to Meet Demand (tested September 2006-January 2008)
• Using an ED Predictive Model, the team evaluated clinician scheduling patterns to match patient arrival times. Adjustments to meet patient demand were made and are continuously monitored to reflect seasonal changes in census; staffing is increased or decreased as needed.
• Team-based care was instituted. Teams were identified as A-B-C-D and assigned to geographic zones; this was used to organize admissions to the ED. The ED Team worked to determine the appropriate assignment for each team and did PDSAs to assess implementation. This work pattern allows continuous assignment of patients as opposed to separating patients into segments by diagnosis.

• Early Warning and Response to Large Fluctuations in Capacity (tested February 2006-January 2008)
  • Initiated the “bed ahead” program, in which bed requests are generated once an inpatient admission is determined rather than waiting for the order to be documented by the physician.
  • Utilized “patients waiting” as a trigger to initiate increase staffing needs; a “triage alert” was utilized whenever more than two patients were in the queue, with response by Clinical Manager and Charge Nurses.
  • Collaborative improvement cycles were initiated between radiology and laboratory to decrease turnaround times (TAT). New computerized tomography (CT) dosing protocol was put in place; this reduces dosing time from 195 to 60 minutes for exams, excluding differential diagnosis of appendicitis or diverticulitis, and reduced dosing time from 195 to 90 minutes for these exams. There are very few "re-takes" due to inadequate contrast. A positive patient ID bar code system pilot was initiated which also notifies phlebotomist when labs are ordered.

Results