The emergency department (ED) is no longer just the hospital’s often-overcrowded front door for medical emergencies, accidents, and trauma — or a safety net for people who lack access to care. EDs serve as diagnostic centers and as a critical intersection between inpatient and outpatient services. That’s a very broad-based responsibility.
Many hospitals have responded to crowding by building larger EDs. The results have been underwhelming: Instead of being small, crowded, and dysfunctional, many EDs are now big, crowded, and dysfunctional. That’s not progress.
At the University of Colorado Hospital ED, which I am privileged to lead, we realized that more space alone wouldn’t save us. So we took a different approach — building a highly integrated leadership team that sets a new standard for emergency care, with the needs of patients (not providers) as the driving force.
Where We Started
In the summer of 2012, the University of Colorado School of Medicine and Hospital recruited me to be its inaugural chair. My mission: Build an academic department of emergency medicine, and prepare for a much-needed ED expansion. At that point, our challenges were enormous:
- Scores of patients were leaving our ED without being treated. Competing hospitals had a robust referral base just from patients who had bailed on us.
- We were on ambulance diversion for at least 8 of every 24 hours, often longer. Other local EDs actually had betting pools on how long it would take us to go back on diversion after we came off.
- Our patient- and staff-satisfaction scores were essentially zero.
- Relationships with referring physicians and the emergency medical services community were broken.
- We had near-weekly visits from the Colorado Department of Public Health because of patient complaints and code violations.
We started, like many well-meaning hospitals, by expanding our space — more than doubling our square footage. But eight months before completion, in August 2013, while presenting our expansion plan to the hospital’s board, we had an epiphany. We saw the blood drain from the CEO’s cheeks as he realized that the double-size ED actually had fewer treatment areas than the old one did. We knew we had to fundamentally change how we delivered care, not just how we designed the space.
The Leadership Structure
First order of business: Build a leadership team. Straightforward, right? Wrong. Medicine is fraught with anachronistic administrative structures, as well as competing and redundant decision-making processes involving many stakeholders (the hospital, doctors, nurses, compliance, finance, and others) who often work in silos and have differing goals. With more than 230 clinical and support staff, and 55 faculty and 68 resident trainees, we needed everyone on the same page. Our mantra: Patients care about getting exceptional care, not who pays your salary.
Our eight-person senior leadership committee, led by the department chair (me) and a hospital senior VP, outlined three core functions: quality, operations, and process improvement (PI). Each function had an 8- to 10-person subcommittee led by a nurse–physician dyad or, in the case of PI, a nurse–physician–engineer triad (all three were seen as equals). To share ideas and avoid redundancies, members rotated among the subcommittees, which had the power to propose process solutions, engage frontline providers, and develop concrete plans within one to two weeks.
Consider, for example, how to deploy nurses, physicians, and advanced-practice providers (e.g., physician assistants) in the ED. The PI subcommittee developed a plan to follow a series of patients, document their every movement, prepare a detailed task analysis of what every staff member who touched a patient did, and then compare the performed tasks with each provider’s scope of work.
The data were startling: High-cost providers (doctors and nurses) were often spending more than half their time on tasks beneath their skill level.
Armed with those data, the operations subcommittee developed, tested, and implemented a solution that included (among other features) team nursing and use of more advanced-practice providers and technicians. We funded the new, lower-cost positions by eliminating higher-cost positions, all without turf battles or job protectionism. And we repeated this efficient process for other reforms, including complicated financial and regulatory decisions.
Six Guiding Principles
How did we achieve this Sisyphean task? We adhered to six straightforward, easily communicated guiding principles:
- Put patients at the center. We made sure every single process, change, movement, and piece of equipment existed because it was better for the patient, not the convenience of the provider. If a team member could not articulate how a proposed change or an existing process benefited patients, it was not even considered. For example, we eliminated triage, an antiquated practice (used to sort battlefield patients in Napoleon’s time) not fit for a modern ED. There’s simply no reason to make patients wait until a provider is ready for them. Now a senior physician starts the care process without delay. The word “triage” is forbidden.
- Use data relentlessly. Accountability requires measurement, so we measured anything that could affect patients. We used the electronic medical record when we could, stop watches and direct observation when we couldn’t. We publicly distributed daily dashboards that included department- and provider-specific measures of process, resource utilization, and quality — in line with departmental goals and compared with national standards if they existed. If we fell short, the operations subcommittee had to correct the shortfall rapidly. Individual providers who didn’t measure up had to follow a remediation plan, with incremental improvements that were documented.
- Speak with one voice. Discipline and philosophical agreement were essential. Yes, everyone was strongly encouraged to play devil’s advocate and offer alternative solutions. But once a decision was made, it was implemented. It helped that we publicly owned the decisions and the results. And we acknowledged missteps and failures — and then fixed them. For example, when the PI team was evenly split on where to place the observation unit within the ED, I made the call. But when we saw it was the wrong choice, we told the entire department why we had made the decision and why it turned out to be wrong — and then fixed it in two days.
- Value everyone’s perspective. People at the front lines of patient care — who practice medicine, run ventilators, stock equipment, transport patients, deliver food, and change linens — had to feel invested in the department’s core mission. That meant explicitly acknowledging the value of their input. For example, a respiratory therapist pointed out that, under certain circumstances, patients would be better served if we brought a portable X-ray machine to them rather than moving them to the machine, even if they were not critically ill. This idea was implemented in less than a week.
- Deliver high-quality care universally. With colleagues in different specialties and with paramedics and firefighters, we identified specific presentations known to be high-risk (heart attack, stroke, major trauma, sepsis) or associated with tremendous practice variability (chest, abdominal, and back pain, headache), to name a few. We then developed over 50 care pathways to guide care and use of resources, to prompt specific interventions, and to inform ordering decisions. Here are just a few of our improvements: Use of high-cost imaging (CT scan and MRI) has dropped by 15%, avoidable hospital admissions have decreased by 20%, and we get patients with major heart attack to the cardiac catheterization lab in less than 90 minutes (the standard) 100% of the time. Our total cost of care per patient is down 18%.
- Set the standard. As an academic institution, we are dedicated not only to patient care but also to innovation and education. This might sound arrogant, but we want to prove that our ideas work — and we want others to follow our standard. To date, 40 academic medical centers from Asia, Europe, and North America have spent time with us to learn our processes, our leaders have been invited to speak about our success on at least 30 occasions, our results will soon be published in an academic journal, and we have been held up as a model by organizations such as the American College of Emergency Physicians, Press Ganey, and the University HealthSystem Consortium.
Our ED has made great strides, and patients are voting with their behavior. Our volume has increased by 53%, putting us on track to become the highest-volume ED in Colorado. Our patient-satisfaction scores are in the top box 77% of the time (not 90%, like we want, but we’ll get there). We have cut our total treatment time by more than 40%; patients now wait fewer than 8 minutes, on average, to see an attending physician. Virtually no patients leave our ED without being seen, and we are never, ever on ambulance diversion.
Although we have vastly improved quality, we still struggle with some measures and with practice variability. So we just started Round 2 of a top-to-bottom process evaluation — CARE 2.0 (Compassionate care, Access, Reliability, and Efficiency) — as we stick to our guiding principles in setting a new standard for emergency care.