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Improving Patient Flowand Reducing EmergencyDepartment Crowding:A Guide for Hospitals

Improving Patient Flowand Reducing EmergencyDepartment Crowding:A Guide for HospitalsMegan McHugh, PhDKevin Van Dyke, MPPMark McClelland, MN, RNDina Moss, MPAOctober 2011AHRQ Publication No. 11(12)-0094

This document is in the public domain and may be used and reprinted without permission.Suggested citation:McHugh, M., Van Dyke, K., McClelland M., Moss D. Improving Patient Flow and Reducing EmergencyDepartment Crowding: A Guide for Hospitals. (Prepared by the Health Research & Educational Trust, anaffiliate of the American Hospital Association, under contract 290-200-600022, Task Order No. 6).AHRQ Publication No. 11(12)-0094. Rockville, MD: Agency for Healthcare Research and Quality;October 2011.The opinions presented in this report are those of the authors, who are responsible for its content, and donot necessarily reflect the position of the U.S. Department of Health and Human Services or the Agencyfor Healthcare Research and Quality.Acknowledgments: The authors would like to express their sincere gratitude to the patient flowimprovement teams from the hospitals that participated in the Urgent Matters Learning Network(UMLN) I and II:iiGrady Health SystemAtlanta, GAUniversity Hospital San AntonioSan Antonio, TXBoston Medical CenterBoston, MAUniversity of California at San DiegoSan Diego, CAHenry Ford HospitalDetroit, MIThomas Jefferson University HospitalPhiladelphia, PAElmhurst Hospital CenterElmhurst, NYHahnemann University HospitalPhiladelphia, PAInova Fairfax HospitalFalls Church, VAStony Brook University Medical CenterStony Brook, NYBryanLGH Medical CenterLincoln, NEGood Samaritan Hospital Medical CenterLong Island, NYThe Regional Medical Center at MemphisMemphis, TNSt. Francis HospitalIndianapolis, INSt. Joseph's Hospital & Medical CenterPhoenix, AZWestmoreland HospitalGreensburg, PAThe authors also thank the contributors who provided important feedback on this guide, includingrepresentatives from: Shore Health System, Easton, MD; UMass Memorial Medical Center, Worcester,MA; and Baptist Health Care, Pensacola, FL.

ContentsExecutive Summary .1Section 1. The Need to Address Emergency Department Crowding .5Section 2. Forming a Patient Flow Team .7Section 3. Measuring Emergency Department Performance.10Section 4. Identifying Strategies .14Section 5. Preparing to Launch .17Section 6. Facilitating Change and Anticipating Challenges .23Section 7. Sharing Results.28References .29Appendix A. Guide to Online Resources Successfully Used by Hospitals to ImprovePatient Flow .31Appendix B. Implementation Plan Template .32Appendix C. Example Implementation Plan .37Appendix D. Additional Readings .43iii

Executive SummaryThe Need to Address Emergency Department CrowdingAlthough you, as a hospital or department leader, are responsible for overseeing performance across anumber of dimensions, there are several reasons why addressing emergency department (ED) crowdingshould be at the forefront of your organization’s improvement efforts:1. ED crowding compromises care quality.2. ED crowding is costly.3. Hospitals will soon report ED crowding measures to the Centers for Medicare & MedicaidServices (CMS).4. ED crowding compromises community trust.5. ED crowding can be mitigated by improving patient flow throughout the hospital.The purpose of this guide is to present step-by-step instructions for planning and implementing patientflow improvement strategies.1Forming a Patient Flow TeamThe importance of creating a patient flow improvement team—and giving careful thought to itscomposition—cannot be underestimated. Numerous studies have shown the benefits of creating amultidisciplinary team to plan quality improvement interventions. We recommend that, at a minimum,your team include a team leader (i.e., day-to-day leader), senior hospital leader (e.g., chief qualityofficer), ED physicians and nurses, ED support staff (e.g., clerks, registrars), representatives frominpatient units, and a research/data analyst. It is important to include representatives from alldepartments that will be affected by your strategy, individuals who will serve as champions for yourstrategy, and those who may oppose your strategy so that their concerns may be heard.Measuring ED PerformanceMeasurement is a fundamental tool to identify and eliminate variation in clinical processes. Data alsocan be used to show that ED crowding is not just an ED problem, but one that requires hospital-widesolutions. Currently, hospitals are required to report several ED quality measures—for example, the coremeasures—and new measures are scheduled to start affecting hospital payment in 2013 and beyond(e.g., median time from ED arrival to ED departure). We recommend all hospitals begin collecting dataon those measures now.Identifying StrategiesSelecting the right strategy is paramount for any successful intervention. Hospitals that devote sufficienttime up front to careful selection of a strategy often save time in the long run by avoiding having tomake major adjustments midstream. We recommend that your team take the following steps beforeselecting your improvement strategy:

1. Identify the most likely causes of the specific problems you face.2. Review available materials that describe what other hospitals have done to improve patient flow.3. Consider your resources.Preparing to LaunchOnce the strategy is selected, we recommend that hospitals create a road map for the implementationprocess. An implementation plan should be completed by the team and can help:1. Identify your goals and strategies.2. Plan your approach.3. Estimate the time and expenses associated with implementation.4. Identify performance measures.Once completed, we recommend that you share your implementation plan with other hospital anddepartment leaders to ensure that they (1) are aware of the efforts underway and (2) understand thetimeline, budget, and resources that will be needed.2Facilitating Change, Anticipating ChallengesFacilitating change often involves anticipating common challenges and taking steps to forestall them.We recommend several strategies for addressing those challenges.Recommended Approaches to Addressing Implementation ChallengesChallengeRecommended ApproachRationaleCulture changeConstant reinforcement of thestrategy by leadersSignals to staff that the improvementstrategy will become standardprocedureStaff resistanceStaff educationProvides staff with the capabilities andknowledge to carry out the strategyStaff resistancePost-implementation adjustmentsreflecting user recommendationsSignals responsiveness to staff concernsStaff resistance, culturechange, and lack ofstaffing resourcesUse of Lean quality improvementmethodsFosters a team environmentLack of staffing resourcesStaff resistanceRobust data collectionProvides concrete evidence of need foraction; demonstrates success to hospitalleaders and frontline staff; is crucial insecuring an executive champion

Sharing ResultsSharing results internally and externally is the key to sustainability and spread. Widely reporting theresults of multi-unit and department initiatives helps create a culture of transparency and openness.Units given the opportunity to compare their performance relative to other units will develop a healthycompetition to improve. We recommend the use of ED dashboards to provide a snapshot of key processvariables of particular interest to internal stakeholders.Though not all hospitals can participate in a formal collaborative, we recommend that all hospitals buildmomentum by sharing their results with external stakeholders through community partnerships, writtenpublications, and conference presentations. Some examples of potential outlets for sharing resultsinclude: community social service organizations that work with the hospital, other hospitals within asystem or in the hospital’s metropolitan or State hospital association, local newspapers and blogs, tradepublications (e.g., Hospitals & Health Networks, Modern Healthcare), peer-reviewed journals (e.g.,Joint Commission Journal on Quality and Patient Safety, Journal of Emergency Medicine, Journal ofEmergency Nursing), and professional societies (e.g., Society for Academic Emergency Medicine,American College of Emergency Physicians, and Emergency Nurses Association).3

Section 1. The Need to AddressEmergency Department CrowdingMany emergency departments (EDs) across the country are crowded. Nearly half of EDs report operatingat or above capacity, and 9 out of 10 hospitals report holding or “boarding” admitted patients in the EDwhile they await inpatient beds. Because of crowding, approximately 500,000 ambulances are divertedeach year away from the closest hospital. ED crowding has been the subject of countless news articles,lawsuits, and research studies.Although you, the hospital or ED leaders, are responsible for overseeing hospital performance across anumber of dimensions, there are several reasons why addressing ED crowding should be at the forefrontof your organizations’ improvement efforts. These include:1. ED Crowding Compromises Care QualityEDs are high-risk, high-stress environments. When capacity is exceeded, there are heightenedopportunities for error. The Institute of Medicine’s (IOM’s) six dimensions of quality (safety, effectiveness,patient-centeredness, efficiency, timeliness, and equity) may all be compromised when patients experiencelong waits to see a physician, patients are boarded in the ED, or ambulances are diverted away from thehospital closest to the patient. Over the past few years, several studies have presented clear evidence thatED crowding contributes to poor quality care.1-52. ED Crowding Is CostlyIn 2007, the most recent year for which data are available, 1.9 million people—representing 2 percent ofall ED visits—left the ED before being seen, typically because of long wait times.6 These walk-outsrepresent significant lost revenue for hospitals. The same is true of ambulance diversions. A 2006 study ata large academic medical center (AMC) found that each hour on diversion was associated with 1,086 inforegone hospital revenues.7 A more recent study conducted at a different AMC showed that a 1-hourreduction in ED boarding time would result in over 9,000 of additional revenue by reducing ambulancediversion and the number of patients who left without being seen.8 A crowded ED also limits the ability ofan institution to accept referrals and increases medicolegal risks.3. Hospitals Will Soon Report ED Crowding Measures to CMSThe Centers for Medicare & Medicaid Services (CMS) announced the inclusion of five ED crowdingrelated measures under the Hospital Inpatient Quality Reporting Programa initiative:nnnnnPatient median time from ED arrival to ED departure for discharged patients (calendar year [CY] 2013).Door-to-diagnostic evaluation by a qualified medical professional (CY 2013).Patient left before being seen (CY 2013).Median time from ED arrival to ED departure for admitted patients (FY 2014).Median time from admit decision time to time of departure for admitted patients (FY 2014).aHospitalInpatient Quality Reporting Program. Overview available at

Hospitals will be required to report these measures to CMS in order to receive the full Medicare paymentupdate.9,10 The measures were endorsed by the National Quality Forum in 2008,11 and they are commonlyused by researchers to assess changes in ED crowding and patient throughput. Eventually, these measureswill be reported publicly.4. ED Crowding Compromises Community TrustThe ED plays a critical role within the community. There is a public expectation that EDs are capable ofproviding appropriate, timely care 24/7, and that they will have the capacity to protect and care for thepublic in the event of a disaster or public health emergency. In addition, there is evidence showing thatphysicians and clinics refer patients to the ED for a variety of reasons,12 including convenience forafter-hours care, reluctance to take on complex cases, liability concerns, and the need for diagnostictesting that cannot be performed in their offices. Because of the high patient volumes that many EDsexperience, the ED may be the clinical area that the public is most familiar with, thereby making it the defacto “public face” of the organization. When crowding leads to long wait times and a decreased ability toprotect patient privacy and provide patient-centered care, the community’s trust and confidence in theorganization may be compromised.65. ED Crowding Can Be Mitigated by Improving Patient FlowOver the past several years, much effort has been devoted to investigating the sources of ED crowding anddeveloping potential solutions. Based on that effort, there is widespread agreement that improving theflow of patients in the ED and throughout the hospital holds promise for addressing ED crowding. Anumber of hospitals have implemented patient flow improvement strategies that have resulted inreductions in measures of ED crowding. As a result, numerous organizations—including the Institute forHealthcare Improvement, the Joint Commission, and the Institute of Medicine—have encouraged hospitalleaders to adopt patient flow improvements.12-14The purpose of this guide is to present step-by-step instructions for planning and implementing patientflow improvement strategies. The guide contains real-world examples of how hospitals have implementedthese steps, the pitfalls they encountered, and strategies used to overcome them. The guide is intended fora broad audience, including hospital chief executive officers, chief quality officers, risk managers, EDdirectors, ED clinicians and staff, and others with an interest in reducing ED crowding.The information in this guide was compiled from the experiences of the hospitals affiliated with UrgentMatters, a national program funded by the Robert Wood Johnson Foundation dedicated to finding,developing, and disseminating strategies to improve patient flow and reduce ED crowding. In 2002,Urgent Matters launched its first learning network with 10 hospitals. The hospitals worked together in acollaborative learning process and received technical assistance to develop and implement best practicesto address ED crowding. Results are summarized in the report Bursting at the Seams: Improving PatientFlow.15 In 2008, Urgent Matters launched a second learning network with six hospitals. The secondlearning network included a formal evaluation of the patient flow improvement strategies, including thefacilitators and barriers to implementation, the time and expenses associated with implementation, and theimpact of the strategies. Results of that evaluation are summarized in the report Improving Patient Flowand Reducing ED Crowding: Evaluation of Strategies from the Urgent Matters Learning Network II.16

Section 2. Forming a Patient Flow TeamNumerous research studies have shown the importance of creating multidisciplinary teams to plan qualityimprovement interventions.17,18 One of the benefits of a multidisciplinary team is that members will bringdifferent perspectives and knowledge about problems, their underlying causes, and potential solutions.Members may also be able to offer different resources and encourage buy-in for the solutions among theirpeers. For all these reasons, identifying the right individuals to participate in implementing the patientflow improvement strategies will be central to the success of your effort. Once formed, the team shouldmeet on a regular basis (e.g., weekly) throughout the planning and implementation stages.Based on the experience of the Urgent Matters Learning Network (UMLN) hospitals, we recommendthat, at a minimum, your team include a team leader (day-to-day leader), senior hospital leader (e.g., thechief quality officer), individuals with technical expertise related to the strategy, ED physicians andnurses, ED support staff (e.g., clerks, registrars), a research/data analyst, and representatives frominpatient units.The experience of the UMLN participants highlighted the important—yet often unrecognized—rolesplayed by registrars, clerks, and technicians, as well as other ED support personnel in the successfuladoption of strategies and the need to include these individuals in planning and implementation. Inaddition, many of the UMLN participants stressed the importance of obtaining the explicit support of thechief executive officer (CEO). The CEO does not necessarily need to serve as your system leader, but averbal expression of support or approval of resources from the CEO signals to staff that the strategy isimportant to the organization.As you assemble your team, we recommend that you consider these questions:1. Who will lead your team?The Institute for Healthcare Improvement recommends that quality improvement teams include threetypes of leaders: a day-to-day leader, a senior hospital leader, and a technical leader.19 The day-to-dayleader is responsible for seeing that tasks are completed on time and motivating the team when challengesare encountered. He or she is also responsible for communicating information about the strategy to theteam and to relevant parties outside of the team. This individual will need sufficient time to devote to theimprovement strategy. The day-to-day leader should be someone who is able to work effectively withothers and someone with sufficient authority to have his or her requests heeded.Senior hospital leaders are those with sufficient authority within the organization who will be able toassist when barriers arise (e.g., chief nursing officer, chief quality officer). They are able to recognize theimplications of the quality improvement effort for the organization and all affected departments.Importantly, the system leader should be someone who can assist with the acquisition of resources tosupport the strategy, as needed.A technical leader is someone who will be able to offer technical support or guidance to the team. Forexample, if your strategy involves changing a form on your electronic medical record, your team willlikely need a technical expert from the information technology (IT) department. A technical leader alsomight be someone who understands processes of care within your organization. For example, a strategy7

to improve flow within the fast track might require a fast track nurse who understands the steps that eachpatient goes through from admission to discharge in the fast track. Teams are likely to require multipletechnical leaders, for example, a technical leader fo

Emergency Nursing), and professional societies (e.g., Society for Academic Emergency Medicine, American College of Emergency Physicians, and Emergency Nurses Association). 3. Section 1. The Need to Address Emergency Department Crowding Many emergency departments (EDs) across the country are crowded. Nearly half of EDs report operating

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