The document summarizes strategies for transforming emergency care delivery through quality improvement initiatives. It discusses how overcrowding in emergency departments can negatively impact patient outcomes and experience. It recommends taking a data-driven systems approach to improve wait times, throughput, and left without being seen rates. This involves creating an analytics dashboard to provide insights, revising high-impact workflows like triage and registration, and engaging leadership and staff. The document also shares how one health system was able to significantly reduce length of stay and left without being seen rates through such efforts.

1. Emergency Department Quality Improvement:
Transforming the Delivery of Care

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Transforming Emergency Care
This report is based on a 2018 Healthcare Analytics Summit (HAS 18)
presentation given by Linda Hummel, MS, BSN, RN, Vice President of Quality
and Patient Safety at Mission Health System and Rick Lee, MSN, RN, CEN,
NE-BC, Executive Director of Emergency Services at Mission Health System,
entitled “Transforming Emergency Care with Analytics and Technologies.”
Linda Hummel, RN, BSN, MS
Vice President, Quality and Safety
Mission Health System
Rick Lee, RN, MSN, CEN, NE-BC
Executive Director, Emergency Services
Mission Health System

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More than half of all U.S. hospitals report over-
crowding in the Emergency Department (ED).
One-third report an increase in ambulance
diversion and 90 percent report they
frequently operate at or over capacity.
This risks the ability to effectively provide
emergency care to those who need it and
contributing to patient dissatisfaction.
Transforming Emergency Care

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Overcrowded EDs cause problems for both
hospital patients and staff, such as increased
wait times, length of stay (LOS), medical
errors, and mortality rates, as well as
financial losses to hospitals.
A data-driven systems approach can
dramatically improve every aspect of
emergency care, improving wait times and
throughput, reducing left without being seen
rates, and improving patient satisfaction.
Transforming Emergency Care

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Crowding in the ED has become a widespread
problem in hospitals across the country for two
primary reasons:
Emergency medicine is the only specialty
with a federal mandate to provide care to
patients seeking treatment.
A shortage of primary care providers has
forced more sick people to seek treatment
in hospital emergency rooms.
Common Problems with Emergency Care
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This overcrowding leads to a number of common
problems with emergency care that can be seen
as markers of hospital health.
Patients walking out of the emergency
department without being seen.
When customers vote with their feet,
this presents three risk factors:
‒ Customer satisfaction
‒ Health
‒ Financial
Common Problems with Emergency Care
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Excessive wait times
In May 2014, the Centers for Disease Control
and Prevention (CDC) reported average
emergency department wait times
were roughly 30 minutes.
Common Problems with Emergency Care
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Volumes negatively impacting throughput and patient
Common Problems with Emergency Care
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Hospitals need a coordinated system effort in
order to improve throughput, however Emergency
Departments can focus on some specific metrics
such as Median LOS for discharged patients,
Median LOS for admitted patients, and Median
LOS for behavioral health patients to improve
throughput and patient experience.
However, factors such as operating room
schedules, inpatient capacity, and increased
behavioral health problem affect volumes and
throughput and need to be addressed on a
system-wide level.

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As the crisis of emergency care grows,
hospitals have more pressure to make
improvements in addition to the many other
pressures facing the healthcare industry.
Redesigning the delivery of emergency care
involves a four-step approach:
1. Ask the right question
2. Create a vision
3. Use an analytics platform
4. Engage staff and stakeholders
Redesigning the Delivery of Care Through
Emergency Department Quality Improvement

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1. Begin with the bigger aim and ask: “What do we need to
best deliver emergency care?”.
Redesigning the Delivery of Care Through
Emergency Department Quality Improvement
Improving emergency care will tie into the
Triple Aim of healthcare improvement:
improving the patient experience of care,
improving the health of populations, and
reducing the per capita cost of healthcare.

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2. Create a vision and support for a data-driven systems approach
to improving emergency care.
Redesigning the Delivery of Care Through
Emergency Department Quality Improvement
Many times, a department will embark on an
improvement project, but don’t think about how it
will affect the flow of other teams or departments.
Instead, it can be helpful to create an ED Joint
Practice Team where anyone who touches the
patient is part of the care team.
This helps improve communication between
departments to avoid unforeseen consequences
of changes to other departments.

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3. Using an analytics platform, develop an ED analytics application
that provides insight into performance.
Redesigning the Delivery of Care Through
Emergency Department Quality Improvement
If an ED with 65 beds has 130 patients come
through the doors on any given day, but the OR
doesn’t know, nor does the hospital care control
center, the ED is operating in isolation without the
ability to resolve issues or foresee them in advance.
Using an analytics application such as ED Explorer,
frontline leadership and executives have the ability
to track throughput, and obtain actionable data
necessary for demand/capacity management.

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4. Engage frontline staff, key stakeholders, patients,
and families in improvement.
Redesigning the Delivery of Care Through
Emergency Department Quality Improvement
Improving ED throughput is much more than
an emergency department initiative, it must
include the entire system of care for real,
lasting change to occur.

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To prevent the ED from operating in isolation, it’s
necessary to involve hospital leadership and other
frontline leaders in the improvement process.
One way to do this is utilizing executive
dashboards that show a snapshot of the ED
performance on a regular (perhaps daily) basis.
Dashboards might show C-suite how many
patients are in ED, how many are waiting to
be seen, wait times, and the number of
behavioral health patients.
Understanding ED Performance

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One of the most telling metrics used in an executive
dashboard is the longest wait time recorded or the
longest wait time for a bed to be assigned to an
admitted patient in the last 24 hours.
Using executive dashboards can help
keep stakeholders informed and involved.
Increased leadership visibility and engage-
ment can greatly contribute to success.
Understanding ED Performance

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In addition to the daily snapshot, executives
might be given access to look ED goals, past
performance, patients left without being seen
percentage, and admission trends.
Using an Emergency Services application such
as ED Explorer can help provide the data
necessary to track, trend, and predict resources
need in the delivery of quality emergency care.
Additionally, a robust ED analytics application
allows users to identify and quantify areas of
opportunity in throughput, ancillary resource
allocation, utilization, and quality.
Understanding ED Performance

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Understanding ED Performance
Figure 1: Snapshot of ED Explorer analytics application that provides multiple views of data for the efficient
day-to-day Emergency Department operations.

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What using an analytics application does is
help users understand ED performance
based on data. That data can then be used
to predict and improve performance.
For example, using analytics, ED leaders
can better understand patient arrival times
and their impact on ED throughput.
This data can be surprisingly predictable.
Understanding ED Performance

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For instance, a hospital might find that if 30 or
more patients arrive within one hour of each
other, ED wait times skyrocket up to two hours.
Then, if 30 or more patients are checked in
within an hour, the analytics application can
notify relevant stakeholders and departments
about surging volumes in the ED.
If the ED is the frontline, the imaging
department might be the next department
to experience large volumes–and wait
times as a result.
Understanding ED Performance

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In looking to tackle Emergency Department
quality improvement projects, hospitals should
look for high-impact opportunities.
Revising high impact workflows such as
streamlining registration and provider triage
can have real, impactful results on ED wait
times, patients left without being seen
percentage, and patient experience.
Revising High Impact Workflows

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Some of the workflow areas to focus on include:
Improved triage workflow.
Provide earlier access to provider using
a triage advanced practitioner.
Redesign discharge process to reduce
non-value-added time.
Implement readiness huddles.
Improve response to surges in patient volume.
Revise staffing patterns.
Add flow coordinator during busy times
to oversee hospital patient flow.
Revising High Impact Workflows
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With a robust analytics application, Emergency
Department leaders can gain valuable insights
into improving staffing patterns to maximize
efficiency.
What department leaders need to ask is:
“Do we have the right amount of staff
at the right times in the right places?”
What hospital leaders might be surprised
to learn is that ED volumes can be
surprisingly predictable.
Revising Staffing Patterns

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Using an analytics platform, healthcare leaders can gain use following insights
into volumes to help inform their staffing patterns.
Identify seasonality in volume trends.
Identify weeks with consistently high-volume.
Utilize this data to predict upcoming
high-volume periods.
Adjust staffing matrix to meet trends.
Use historical trends to plan for holiday or
other identified periods of high census.
Use historical trends to open and close
sections of the ED to align with demand.
Revising Staffing Patterns
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One hospital found that the busiest day
of the year was the Monday following
Superbowl Sunday during a retrospective
three-year review of ED census.
Having access to this data and the ability
to use it to identify trends, understand and
respond to surges in volume, and predict
the resources needed help improve the
efficiency and quality of care provided in
Emergency Departments.
Revising Staffing Patterns

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Communicating leadership expectations is a
crucial component of success.
Because ED performance is a key indicator of
hospital health, it’s necessary for hospital
leaders to be actively engaged in the
department and its improvement efforts.
It may be helpful to identify an executive such
as the Chief Nursing Officer of Vice President of
Quality and Safety as an Executive Sponsor for
the improvement work.
Setting Leadership Expectations

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Additionally, keeping executives informed and
involved through daily rounding, participation in
surge calls if needed, and receiving daily ED
performance reports.
Setting Leadership Expectations

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As healthcare becomes more patient-centric,
it’s more important than ever to improve the
patient experience.
According to Becker’s Hospital Review,
improving patient satisfaction begins in the
ED. In order to being improving patient
satisfaction in the ED, the quality of care
must be consistent.
Additionally, hospitals must purse patient
feedback in order to identify high impact
areas of focus.
Improving the Patient Experience

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Below are some ideas for improving the patient experience in the ED:
Facilitate weekly huddles to review patient feedback.
Ensure leadership makes clear that patient
experience is a priority for the entire team.
Exchange security FTEs for “Guest Services.”
Conduct patient experience training.
Consider embedded care management in the ED.
Have leaders perform daily rounds.
Reinforce common patient experience best
practices and expectations.
Improving the Patient Experience
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Mission Health faced a number of challenges in
its ability to deliver effective emergency services.
Large numbers of patients were walking out of
the ED without being seen by a provider, and, on
average, patients waited more than 50 minutes
to see a qualified medical provider.
They embarked on an Emergency Department
quality improvement mission to improve their
patient flow, patient experience, and ED
throughput with a data-driven approach.
Getting Results

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In a little over one year, Mission Health dramatically improved all aspects of
ED throughput, including:
Getting Results
Nine percent relative
reduction in the rate of
patients who left without
being seen (LWBS),
resulting in the current
performance of 0.4 percent.
29 percent relative
reduction in the time from
discharge order to ED
departure time.
24 percent relative
reduction in the median
length of stay (LOS) for
patients who are
discharged.
Changes in triage and treating patients who are not as acutely ill in a
more space-efficient environment also contributed to a decreased LOS.
With these changes, patient satisfaction doubled.

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Although improving care in the ED is a high
priority for many hospitals, it’s important to have
realistic expectations and prepare for success.
Emergency Department quality improvement is
a journey that takes time and improving ED
performance is much more than an emergency
department initiative–it must involve the entire
system of care.
Additionally, using a data-driven approach can
help engage stakeholders and make a
compelling case for change.
Embarking on an ED Transformation

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Changing the entire system of care requires
excellent leadership and leaders need to
pace themselves so then can effectively
lead the change.
Embarking on an ED Transformation

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For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

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More about this topic
Link to original article for a more in-depth discussion.
Emergency Department Quality Improvement: Transforming the Delivery of Care
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Elaine St. James, BSN, RN, CPHQ, Patient Safety Services; Josh Ferguson, Clinical Outcomes Improvement, Director
Nancy Casazza, BSN, MMI, RN, Clinical Outcomes Improvement, Director
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Ann Tinker, MSN, RN , Professional Services, Sr. VP
How UPMC and Health Catalyst Improve Outcomes Using Innovation in Activity-based Costing
Kyle Salyers, Sr. VP

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Other Clinical Quality Improvement Resources
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