Urgent Matters E-Newsletter
Volume 6, Issue 1
September/October 2009
Special Focus Issue- Performance Measurement
Urgent Matters Learning Network II
Improving Patient Flow and Reducing Emergency Department Crowding
For the past seven years, health care leaders from around the country have been partnering with EDs across the country to develop and deliver strategies to improve patient flow and reduce ED crowding. Working under the banner Urgent Matters (UM) and funded by the Robert Wood Johnson Foundation (RWJF), these innovators are poised to improve care in what has become hospitals’ highest-traffic area, a place where the uninsured routinely flock and where entire communities will invariably turn in the event of a pandemic outbreak or terrorist attack.
"Urgent Matters started at a time when there was a growing realization that emergency departments were the safety net for the stafety net," recalls Bruce Siegel, dorector for the Center for Health Care Quality in the Department of Health Policy at GWU's School of Public Health and Health Services. "It was also after 9/11, and it was absolutley critical that there be high-performing EDs across America. A lot of folks felt you couldn't really fix the problem of overcrowding as long as people were coming to EDs because they has nowhere else to go. But there were lots of things hospitals could do better. First, they could measure things. Second, they could take concrete action on those measurements."
In other words, the time for theorizing and postulating was past. Urgent Matters wanted empirical data from real world scenarios. During its first phase, from September 2002 to April 2004, UM organized a “Learning Network” of ten hospitals that developed and implemented strategies to improve ED flow through “rapid cycle changes,” or small modifications in treatment processes that could be quickly evaluated and retained or dropped, depending on their success. The second phase, from May 2004 to February 2008, UM established a “national platform” for the hospitals’ findings, folding them into a “best practices toolkit” and hosting a series of Webinars now archived at the initiative’s Web site (http://urgentmatters.org).
Urgent Matters entered its third phase — a second Learning Network (LNII) cosponsored by RWJF and the Agency for Healthcare Research and Quality (AHRQ) — in November 2008. This phase consists of two distinct but interdependent “components”: one component is comprised of six hospitals working to identify strategies to improve ED flow in a similar manner as the ten hospitals in LNI. Under the second component, the same six hospitals will collect and report on seven standardized performance measures, three of which have already been endorsed by the National Quality Forum as sound benchmarks of care. The data gathered from LNII hospitals will inevitably inform quality reporting by hospitals in the future.
“We found in first Learning Network that hospitals really could make a difference in improving the care of their patients and making more timely assessments,” Siegel says. But there was clearly more work to do — refinements to be made. This is where LNII comes in.
“In LNI, we were in new territory,” Siegel says. “We had nothing to begin with, and we did a lot of experimenting with things that didn’t work. Now we know a lot more about what works. There are strategies that we already know are not worth trying, which gives the hospitals a leg up and helps them move more quickly from things that are purely experimental to things that work and are ready for wider adoption.”
“We now have a real package of tools and strategies that we didn’t have in LNI. We have a toolkit that will be public eventually, we have measures that are tested and that have been endorsed by the National Quality Forum that will probably wind up in Hospital Compare in next three years. All the pieces are now coming together, so what was a big experiment seven years ago is now becoming reality.”
The Six LNII Hospitals
Hahnemann University Hospital and Thomas Jefferson University Hospital
Hahnemann, a 640-bed private hospital in Philadelphia, and nearby, Thomas Jefferson University Hospital, 765-bed not-for-profit private will be refining “fast track” procedures. “Fast track” is a process that, in ED lingo, strives to “keeps patients vertical.”
ED care has historically been “linear,” with all but the most gravely ill patients subjected to a tedious and time consuming process of registration, triage, consultation, and diagnostics, with long wait times in between each of these steps. The fast-track short circuits this by getting patients who don’t need significant resources in faster, getting them seen by a provider faster, and getting tests done faster.
Stony Brook University Medical Center
Getting an on-call specialty consult can be a very time-intensive, so Stony Brook, 540-bed public hospital in Stony Brook, NY, will be working on streamlining and improving the process.
St. Francis Hospital
St. Francis, 230-bed not-for-profit private hospital in Indianapolis, is standardizing its triage processes so all nurses provide a consistent, high quality process. The St. Francis team is also working to coordinate quick registration and shorten the length of time patients spend in the ED waiting room.
Good Samaritan Hospital Medical Center
A 437-bed not-for-profit teaching and community hospital in West Islip, Good Samaritan will be honing a fast track process specifically for Triage Level 3 patients, a group it’s vital to treat quickly. Under this experimental process, Level 3 patients will be seen by physician on arrival, tests will be ordered, and the patients go to a specifically identified area where they will be given special skilled monitoring.
Westmoreland Hospital
This 301-bed not-for-profit private hospital in Greensburg, PA, is working to improve communication between the ED and other inpatient departments through the hospital with the goal of getting patients “upstairs” faster and improving hospital efficiency overall.
Strength, and Wisdom, in Numbers
The power of LNII, notes Siegel, lies in the ability of hospital EDs both to learn from one another and to collaboratively spearhead measurable progress.
“These are six organizations — six cultures —coming together to try to solve problems and share their experiences,” Siegel says. “The most powerful thing about a network like this is that they’re learning from each other; they’re sharing their frustration and figuring out what works. Urgent Matters can only do so much, but organizations like this and their leaders can truly affect change.”
After the data is gathered by the LNII hospitals, the Health Research & Educational Trust (HRET), an affiliate of the American Hospital Association, will conduct research into the benefits and challenges associated with implementing the strategies developed under LNII based on interviews with participating hospital staff.
Results from LNII will be spread through the Urgent Matters Web site and E-Newsletter, published papers, and conferences involving UM, RWJF, AHRQ and HRET.
“There are thousands of people hungry for this information across America — thousands of people who are struggling with these issues every day. It’s an area of intense interest and energy. We’re talking about EDs that get over 119 million visits per year. This is serious business, because if you can’t get this right, you can’t get health care right.”
Ultimately, says Siegel, the work that LNII hospitals have undertaken is about helping the healthcare system develop a realistic picture of how well it’s serving patients. It’s also about changing deep-rooted and, ultimately, dangerous beliefs about EDs.
“When we started out, many people in senior hospital leadership positions didn’t value emergency departments the way they should,” Siegel says. “It was a place that got crowded and chaotic at night when they were not there to see it, and the problems solved themselves every night and were gone by the time they got in the next day. Moreover, it’s often a less profitable service and was often not viewed as worth investing in. The people who run the emergency departments — the physicians and the nurses, really can’t solve this problem because crowding and the solutions for it aren’t totally in their control. The issue needs a hospitalwide response.”
Bruce Siegel, MD, MPH, Director of the Center for Health Care Quality, Department of Health Policy, George Washington University School of Public Health and Health Services
