Urgent Matters E-Newsletter
Volume 6, Issue 1
September/October 2009
Special Focus Issue- Performance Measurement
Best Practices
Creating Sustainable Change Through Quality Improvement Projects
Most people with an urgent medical need breathe a sigh of relief when they arrive at the doors of their local emergency department. Even if they’re made to wait for care, there’s a comfort, a peace of mind that comes from being so close to trained clinicians and life-saving equipment.
But Mel Stibal, administrative director of the Emergency Department/Trauma Center at Memorial Regional Hospital in Hollywood, Florida doesn’t see it that way.
“Our philosophy is that the waiting room is the most dangerous place in our hospital,” Stibal says. Her reason is simple and surprisingly intuitive: “We don’t know what’s going on with the patient in the waiting room. They haven’t been evaluated yet.” Complications can develop quickly during the wait and the most stable-looking patient can suddenly take a turn for the worse. As Stibal adds wryly, “I don’t want my hospital on the front of U.S. News.”
It is for this reason that Stibal and her colleagues embarked in 2007 on an ED improvement process with the help of the Institute for Healthcare Improvement (IHI). At the time, Stibal recalls, “we were struggling with many of same issues that EDs across the country struggle with: long wait times, delays in getting patients to inpatient beds, high ‘left without being seen rates,’ low patient satisfaction, poor staff morale, and high nursing turnover. We were looking for ways to be better.”
Part of Hollywood-based Memorial Healthcare System, Memorial Regional Hospital is a 690-bed Level 1 trauma. Its adult ED sees 85,000 visitors annually, and it was here that Stibal directed the improvement efforts focused on staffing development and building the right team and mix of health professionals. Ultimately, by focusing on demand and capacity and using Centers for Medicare and Medicaid core measures, the hospital was able to decrease clinical variability and, consequently, increase patient and workforce satisfaction.
While the process of improvement was complex, the results have been staggeringly straightforward.
“We’ve had very significant impact on throughput times on three services: quick care, treatment-and-release, and admissions times,” Stibal says. Since joining the initiative, Memorial Regional has reduced its average throughput time for admitted patients by nearly three hours (from roughly nine hours to less than six), its treat-and-release times from six hours to three or less, and its left without being seen rates from 13% to 2%. Patient satisfaction, which was once at the 18th percentile, is now routinely at the 95th percentile or above. And nurse vacancy rates, at one point greater than 20%, are now steady at around 5%.
Focus on Patient Flow
The starting point for Memorial Regional’s ED was clear to the entire staff.
“We had to improve our results from the waiting room to the treatment room,” Stibal recalls. “Once we were able to get a hold of those, everything else just seemed to fall in line.”
The key to success was changing the triage system, Stibal explains. The ED initially had a critical care area and a less acute area. One area frequently would become overwhelmed while the other would be virtually empty. “That created conflict between the two areas and delays,” she says.
The solution was to change the way their ED processed patients. They dropped the two-area system and created four 16-bed “pods” called simply Pod A, Pod B, Pod C, and Pod D. Each pod was assigned a charge nurse, a physician, a clerical person, a technician or paramedic, and four
bedside nurses. Patients, whether walk-ins or rescue patients, were assigned to the pods in equal distribution patterns, so no pod ever became overwhelmed while another had few patients. Meanwhile, resources were used more wisely. Instead of stocking all resources in every room, staff devised mobile carts that could be moved quickly to patients in need of them.
The difference between the new and old systems, says Stibal, was "huge."
Improving Bed Management
Another tool devised by Memorial Regional under the program was the “bed ahead” program. Under this system, the minute the ER physician determines that a patient needs to be admitted, the ED makes a formal request for an inpatient bed rather than waiting for the ED physician to get admission orders from the patient’s primary care physician.
“We do a tentative diagnosis so we know what kind of bed we’ll need, and we’re pretty spot on,” Stibal notes. “The diagnosis is changed less than five percent of the time.”
“It has absolutely increased efficiency,” Stibal says. “It’s decreased the time from when we request a bed to when the patient is taken there by 2 hours. It gives more motivation to the nursing unit receiving the patient, too. If they know the ER has five patients who are going to come to their unit, they can make arrangements for staffing and move existing patients around to accommodate the new ones.”
Using Rapid Cycle Changes
Stibal says her staff was able to hit upon successful modifications to ED processes because of the “rapid cycle changes.”
“Instead of implementing something and testing it for weeks,” Stibal explains, “we take a small portion of a process and test it for one or two days, then revise it and retest it.”
Rapid cycles changes helped Memorial Regional hit upon the “pod” system and the bed-ahead program, and it also helped with smaller modifications. For example, the ED determined through a rapid cycle change that it should increased staff on Monday and Tuesday for more efficiency.
Stibal says adopting rapid cycle changes is great for staff morale, as it engenders an environment of flexibility and open-mindedness.
“It garners support from your staff because if there’s anything they want to try, you do it and get feedback and change it as it needs to be changed,” she says. “You get a small group on board, and they help spread it. It lets you achieve a much greater degree of staff buy-in.”
Challenges
Stibal says the most difficult aspect of the initiative “was keeping everybody engaged, because it went over two years. We had a core team of people that worked on the project, so keeping them vested over a two-year period was a challenge. If I could change anything, I would broaden the group and continually bring people in so they got exposure.” Nevertheless, support for the initiative from top hospital administrators was strong.
“Everybody really bought in because everybody is used to the ED being the black eye of the hospital, so they were really invested in improvement,” Stibal says. “In most hospitals, unless they’re stand-alone specialty hospitals, the majority of admissions come in though the ED. So ensuring there’s a smooth flow of patients into the facility is important.”
Stibal notes that the culture of an ED isn’t easy to change — that “it’s a very long, painful process that takes time and perseverance” — but that the end result is well worth it.
“My staff is happy and engaged,” Stibal reflects. “I’ve been a nurse for almost 30 years, and instead of barraged with complaints on a daily basis, I’m met smiling faces. To have that type of people working and taking care of your patients is a great thing. They’re able to put aside all the little criticisms to take care of patients.”
Ask her how she knows the changes she’s made in her ED have been successful and she doesn’t have to think about her answer.
“It works when I’m not here,” she says. “It’s not dependent on any one person.”
Melinda Stibal, MSN, MBA, Administrative Director, ED/Trauma, Memorial Regional Hospital Hollywood, Florida
