The Emergency Department of Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago’s largest pediatric provider, handles 60,000 visits a year. The ED has been open since 2012, when the hospital (formerly known as Children’s Memorial) moved from the residential neighborhood of Lincoln Park to a more central location in Streeterville, adjacent to Northwestern Memorial Hospital and the Feinberg School of Medicine. The new hospital added 90 beds — a 33% increase — with a corresponding increase in ED capacity and resources.
Despite the greater capacity, by December 2016, the pace of ED operation had slowed down, and length of stay had increased 20%, for reasons that were not clear until we analyzed patient flow. The increase in length of stay hindered our ability to serve our patients effectively, and stressed both patients and staff (who either left the department or became disengaged, damaging the collegial culture that had been one of our ED’s most valuable assets). This paper describes the operational and cultural changes we made that have reduced length of stay by 11% and have helped restore our esprit de corps.
The triad of leadership between nursing, medical, and operations is critical to success. Each brings skills and relationships that make the team strong. By relinquishing the “fix it all yourself” mentality, the team has been able to make significant strides.
It’s critical to test changes as part of the system. While incremental improvement and marginal gains are pivotal to long-term success, combined efforts and comprehensive testing (versus siloed tests of change) have yielded benefit more rapidly.
Have a system to oversee, modify, and evolve. Entering high season with the flu, our daily volume increased. The ED experienced volume not seen in a month since H1N1 in 2014, averaging 200 patients per day with levels as high as 250. Through weekly EDOC meetings, we have modified several times the hours of operation of our interventions, as well as the staffing and system that surrounds them. Our staff have also become more agile at adapting to fluctuating conditions.
Change systems can be built and driven locally, with structure, transparency, and strong local leadership.
“Just try it” and keep moving. It was scary for many to do something drastically different. We had to move together and take the leap, and now everyone is more comfortable with change.
It is hard to maintain the pace and sense of urgency in the summer “slow” season.
Taking the time to understand how to improve is as important as improving. We are actively working on sharing the process that we used to accomplish these improvements, at the executive level and throughout the hospital.
In January of 2017, our average Emergency Department length of stay was 3:11 hours, above the target for the department at 3:00 hours. While 11 minutes may not sound like a lot, the average masked a wide variability. Daytime patients might move through faster than average, while wait times between 4 p.m. and midnight, when we see 60 to 70% of our patients, could exceed 3 hours. Our resources are particularly stressed during flu season, and we often see 250 patients a day in the winter (compared with about 140 in the summer).
We have 30 ED exam rooms (divided into three 10-bed pods), a procedure room, and two trauma rooms that hold four patients each.
The leadership team agreed to take a comprehensive approach, rather than pursuing fragmented solutions that might increase dysfunction elsewhere, and to involve the entire staff in redesigning care and transforming our culture.
Developing an Infrastructure — Design and Execution
The ED team developed an infrastructure and management system that integrated the Lean management philosophy, focusing on continuous improvement, and a recognition that patients are at the center of all we do and we need to align our goals accordingly, rather than structuring our activities for the convenience of the staff. The system included the following elements:
- ED Operations Committee (EDOC): A standing multidisciplinary oversight committee with 12 members comprising ED staff and related areas like patient access and registration and environmental services. Meeting weekly, the group guides improvement initiatives, provides resources and team members, manages follow up issues, tracks progress and mitigates barriers, and develops communication points for management bodies in other parts of the organization. An EDOC liaison attends the monthly house-wide throughput and capacity meeting.
- Project Teams (Front Line) and Shared Responsibility Structure: Frontline team assignments were pre-planned including dedicated off-unit time to work on initiatives. Given a budgeted timeline and resources, project teams with four to six members are responsible for leading project sub-groups and reporting back on progress to the larger EDOC group.
- Communication Plan: We adopted multi-modal communication plan at the start of the fiscal year, including a quarterly print newsletter, a biweekly communication on updates to the department every pay day, and a 1-hour update for everyone on the ED staff every quarter. We provide six sessions over 3 days to allow staff members to attend this update as their schedules permit.
- Tests of Change Strategy: Our Lean management approach included the Plan-Do-Study-Act (PDSA) model for testing improvement hypotheses. In accordance with PDSA, we created a schedule at the beginning of the fiscal year that designated specific days to test change. This schedule allowed the department to plan for staffing, and to alert staff that we would be trying something new. It also gave the project teams a deadline for completing the planning on their interventions. Each intervention was tested on both a high-volume day (Tuesday) and a low-volume day (Thursday).
- Implementation Dates: As with the PDSA tests described above, each intervention had an implementation schedule set in advance to impose discipline on the process and track progress.
- Education/Hardwiring Strategy: The interventions we tested required changes in our Epic electronic health record system (EHR) to accommodate the new workflows. Our implementation plan included passing EHR change recommendations through the local staff clinical informatics committee, and also through the team handling staff education, so that it could incorporate the changes into its training curricula along with the changes in triage workflow.
Value Stream Analysis Event
In February 2017, the Emergency Department hosted a 2-day value stream analysis event to outline and map all the processes and workflows associated with the Emergency Department, along with gaps, barriers to improvement, and possible solutions (prioritized by vote of the attendees). The event included 40+ team members from the ED, patient access center (house managers), registration, critical care, acute care, and environmental services. The event reviewed many observations and time studies, operational data, and surveys from patients, ED staff, and inpatient staff. The meeting gave us a list of priorities on which to focus.
A Comprehensive and Targeted Intervention Plan — Tangible Improvements
The process described above identified two areas for change:
First, the triage process at the front door could be streamlined. We discovered that we were doing the full triage assessment (head to toe) in Triage even when it could be done in an exam room, resulting in a bottleneck at Triage and empty exam rooms. If we moved some steps to the exam room, the triage nurse could continue to triage at the same time the ER physicians saw patients. When rooms are available, the triage nurse could record name and demographics, chief complaint, acuity, and weight, and then move patients to an exam room. At the same time, when the exam rooms are full, some steps usually done in the exam room could be moved to Triage.
Second, especially during the December to March flu season, many patients who didn’t really need a bed were being placed in precious bed space, which increased our door-to-provider time and delayed care for potentially sicker children, especially during our busiest 8 hours, between 4 p.m. and midnight. Pod 3 was nominally allocated to the lowest-acuity patients (Levels 4 and 5), which sometimes caused a shortage of bed space for higher-acuity patients. We needed to be more precise in how we triaged less acute patients and find a more efficient way to care for them, both to reduce their length of stay and to keep bed space for the most acute patients.
The project teams created the following interventions to address these areas:
We placed a provider in Triage specifically to assess and treat low-acuity patients (Levels 4 and 5) during our busiest times. This provider, an APN or MD known as the Provider in ER (PIER), sees potentially 30 patients per day who would otherwise take bed space in the ED. The PIER is generally available December through March, Sunday through Wednesday, 11 a.m. to 11 p.m.
With additional capacity now available in the back, Pod 3 expanded its acuity criteria up to acuity Level 2 to make up for the decrease in volume of lower-acuity patients and relieve the stress on Pods 1 and 2.
We adjusted our staffing model to better reflect our fluctuations in volume. Previously, we had had a high-season and a low-season staffing plan; now we tier both seasons according to the days of the week, with the highest level for Sunday-Monday-Tuesday, a lower level for Wednesday, and the lowest level for Thursday-Friday-Saturday.
The interventions in concert with one another and with a labor team–approved staffing model to support have, to date, demonstrated valuable metrically driven improvements.
Emergency Department length of stay is down 11%, to 2:50 hours, which is below our goal of 3:00 hours. The PIER provider, using surge bed space for an additional two beds, has seen up to 50 patients in a 12-hour shift. Pod 3, now with increased acuity, has seen an increased volume of Emergency Severity Index (ESI) 2s and 3s (from 0.5% to 6%). Our patient surveys show that we have improved at seeing the lowest-acuity patients in a timely manner and are spending enough time with patients, and our scores now exceed the national average for children’s hospitals.
Moreover, our team feels a difference. Seeing 250 patients per day no longer feels unmanageable but rather a routine winter day. We are now thinking as one ED.
Moving beyond the rollout, adjustments and next steps have already been taken. We are expanding the days on which we run the PIER to accommodate the surge in volume from this year’s flu season. We are also beginning the PIER coverage earlier on our busy days. We continue to see such benefit from the PIER that we have also assessed the waiting room at the start of the shift to determine if this provider should see patients in the unused Triage bays or begin immediately in the surge space for the available added capacity.
No matter the adjustment, the takeaway for the entire team is that we can always review on Wednesday, and if it needs to be addressed, it will be. Our new operating principle is active improvement management.
Patient Family Experience Scores: Low-Acuity Patient Population
Seen in a timely manner:
Before Implementation: 54.8%
After Implementation: 60.4%
Children’s Hospital Association Average: 59%
Provider spent enough time with patient:
Before Implementation: 66.3%
After Implementation: 70.3%
Children’s Hospital Association Average: 68%
Source: NRC Health / Ann & Robert H. Lurie Children’s Hospital Patient Survey