Improving the hospital emergency room:

    This summer, we made the news; unfortunately, for the wrong reasons. My son was bitten by a raccoon. Dealing with a screaming 6-year-old in a state of shock is not an experience that anyone looks forward to. But for me, there was a silver lining — the opportunity to watch the exceptional Newton-Wellesley Emergency Room (ER) team at work.

    The staff were phenomenal, as one would expect from one of the better-rated ERs in the country. They truly did a great job. It was apparent in the staff training, collaboration and the expected level of care that their rating is well deserved.

    At the same time, as a performance improvement coach, I couldn’t help but notice that even the Newton Wellesley Emergency Room isn’t perfect. A few small improvements could make patient experience measurably better and improve medical and financial outcomes while reducing risks.

    In this article, I’ll share both the best practices I observed and the potential improvements I identified. Both can be applied to any ER in the world, helping improve performance and consumer experiences. I’ll start by covering my personal experience.

    MY TIME AT THE ER

    We arrived at 6:00pm. My spouse checked in at reception while I parked the car. There were around 15 people ahead of us in the waiting room. We sat down, my son talking loudly because of the pain and shock that he just experienced. He was bleeding.

    After a few minutes of waiting, I approached the reception desk again, reiterated that my son was bleeding and asked when he could be examined. The receptionist promptly informed the nurse but still could not give us an estimated wait time.

    About 10 minutes later, the triage nurse called us in (ahead of 12 of the 15 people who were waiting). The nurse was outstanding; she calmed us down and helped my son process what had happened, alleviating his fear and anger by helping him understand why animals can sometimes attack people and why there is no need to be angry or scared.

    My spouse and I were very impressed with the nurse’s ability to provide psychological as well as physical relief. I felt like this was something all of us could stand to learn.

    The nurse proceeded to record my son’s vitals, explaining the process as she went and involving him in it. Next, we were off to the pediatric wing of the ER. While the wait in the room was not long, we were growing anxious because we had no information as to the timing of next steps.

    At this point, an assistant came in to print out our son’s hand tag and turned on the TV. She left promptly.

    A sports program was on that was not keeping my son’s attention, but we could not find the remote control to change the channel. (In retrospect it was in an obvious place and should’ve been easy to find, but when your adrenaline is pumping, obvious things are not that obvious).

    Next, a different assistant came in to offer my son video games or books, but we were too distraught to process what she was saying. In spite of her best intentions, she was not able to tell us what would happen next or when it would be happening, which made us even less comfortable. The kind of psychological training that the triage nurse had so brilliantly demonstrated 10 minutes earlier would’ve been helpful here.

    Still, the model of staffing the ER with non-medical personnel whose role is to make the patient experience more comfortable is worth noting, even if the implementation is not always perfect.

    After another 10 minutes had passed, a billing specialist came in to take our financial/insurance information. She startled us by rolling in a big unwieldy cart without introducing herself or explaining why she was there. My son tensed up and the cart was blocking me from getting to him. It took us a minute to calm him back down.

    While her communication skills could have been more polished given our emergency, handling insurance processing during the wait made a lot of sense.

    The process of updating our financial information was a bit awkward, and the billing specialist couldn’t tell us anything about what we could expect next. But, at least the process kept us occupied for a little while.

    Fifteen minutes later, the doctor came in and looked at all of my son’s wounds. He indicated that they would clean the wounds and give my son several shots. The doctor then left abruptly, and we were left a bit confused again as to what the timing of everything would be.

    Ten minutes later, a nurse pulled me aside to explain the procedure in more detail. The medical staff would get enough people to wash both the bite spots and inject the medicine in four places, all at the same time.

    It was about 20-30 minutes before the hospital staff were ready, and we did not know what the timeline would be. In the meantime, we were focused on trying to calm our son down: not an easy task when your child knows they’re about to get multiple simultaneous shots. Again, we wished that the doctor and her nurse had shown the same kind of sensitivity as the triage nurse that met us at the door.

    We really wanted to call the assistant who offered us video games earlier, but we had no obvious way to do so.

    Eventually, around six people came into the room all at once, which was intimidating for my son. The doctor did a good job of showing and explaining that the process wouldn’t be a big deal. We held our son, and everyone did their job. It went better than could be expected for a procedure where a child is getting four shots at the same time. Here, the professionalism of the medical team shone through.

    As soon as the procedure was finished, everyone disappeared. We had no clue what would happen next.

    After 20 minutes of waiting, we started looking for anyone who could tell us anything. A nurse showed up after 5 minutes only to tell us that the doctor would have to answer our questions. The doctor showed up 10 minutes later and told us that our questions would be answered at check-out.

    After another 20 minutes, a nurse came in to take care of my son’s bandages and to give us the check-out information. Once we started asking more detailed questions, she called in the doctor and he walked us through the check-out documentation.

    We were told that we were good to go once we’d received medicine from the hospital pharmacy. My son brightened up at first, but it took another hour for his medicine to arrive, which was regrettable because we could have easily picked it up at any pharmacy ourselves.

    At this point, we were discharged – although it took me asking to figure that out. It also took asking to find the exit. In the end, I had to visit a pharmacy to get more antibiotics anyway – but because the whole visit took so long, most pharmacies were closed and that had to wait until the next morning.

    SUMMARY OF EXPERIENCE

    Time in minutes:

    Overall

    Necessary

    Unnecessary

    Wasted time

    Our family spent

    180

    20

    20

    140

    Physician’s time

    30

    10

    15

    5

    Nurse’s time

    90

    40

    30

    20

    Non-medical personnel

    70

    20

    10

    40

    While I can’t remember all of the day’s details accurately, it remains clear that this ER could increase its throughput of patients, reduce operating costs, and improve its patient experience without increasing staff numbers by introducing better procedures, systems, communications, and collaboration training.

    CHALLENGES TO ADDRESS

    1. Quickly determining the level of emergency at reception and prioritizing patients accordingly. Providing the option to self-check in prior to arrival.

    2. Keeping patients apprised of upcoming procedures and estimated delivery timelines.

    3. Providing a way for patients to ask questions without having to interrupt personnel.

    4. Giving all staff members access to relevant patient information so that they can answer questions and deliver better customer service/patient care.

    5. Optimizing patient and personnel flow for maximum efficiency.

    6. Reducing perceived wait times and/or increasing the value of wait times when the wait time is necessary.

    7. Mechanisms for collecting patient and personnel feedback in order to drive continuous improvement.

    CREATING A BETTER ER EXPERIENCE

    In a perfect world, patients could check in via their phone app before arriving at the hospital, indicating their symptoms to give personnel an idea of their emergency level.

    If a patient is unable to pre-check-in, they could do so on-location in one of two ways:

    1. At an automated kiosk
    2. With the help of a receptionist who uses the same prompts and has a second screen visible to the patient to ensure that the information is entered correctly. The space around the check-in kiosks and reception desk would be designed with privacy in mind, e.g. by coming with privacy shields.

    The most urgent emergencies would automatically call up a a pre-triage nurse.

    After check-in, staff can implement the appropriate administrative and medical protocol for each patient based on their symptoms, indicating priority levels using personalized tags issued at check-in.

    In this scenario, the symptoms announced by a patient would alert medical personnel to the severity of the emergency. The staff could then let patients in urgent need of help skip the check-in process altogether. These patients’ tags would be printed with minimal information, or with just a number, then get updated as forms get filled out while doctors and nurses perform treatments.

    In other scenarios, where time is not of the essence, medical and financial/insurance information would be collected prior to the tag getting issued.

    Depending on their symptoms, a patient could be asked to record their own weight, temperature and blood pressure using self-service stations, or to proceed directly to a triage nurse. If a patient has not entered the triage process, they could use an app on their phone or a hospital tablet to fill out as much information as needed based on the triage algorithm. This way, both waiting times and time spent with nurses would be minimized.

    With a process like this, patients could refer to their app or tablet to see how far along they are in their process, and what the approximate wait time for the next procedure is. They could also see follow how requests are sent to the pharmacy, the lab, and other departments in real-time. The app could also direct standardized/general questions to a bot or a human patient advocate depending on the situation.

    The patient advocate would be a clerical non-medical staff member with specialized training. Their key responsibility would be to ensure that a patient has a positive experience, with secondary responsibilities including:

    • Optimization of patient and personnel workflows
    • Ensuring that patients are aware of all relevant information
    • Raising flags on behalf of the patient if the process breaks down.

    In addition to managing expectations, patient advocates would be able to expedite or reroute pharmacy or lab requests to optimize the ER’s flow.

    For example, if a patient is ready for discharge but the pharmacy has not yet forwarded their required medication, the patient advocate would be able to request that the medicine is held at the pharmacy for later pick-up by the patient.

    While the patient advocate is a new role, it doesn’t necessarily require additional personnel. The necessary man-hours would become available as the staff at reception, administration, and billing are asked to do less – and that’s not even counting the reduction in interruptions and wasted time for medical personnel.

    In my specific situation, the assistant that stopped by to offer my son video games and books could have easily handled this role with very little training, meaning no additional staff would’ve been required.

    Giving employees and visitors in the hospital access to the same app would enable them to answer almost any question and eliminate the need for patients to interrupt medical staff. A set of age-appropriate gaming/entertainment options on the same tablet would provide entertainment while patients wait.

    Adding a GPS tracker to staff-side devices issued to every employee could also help find the personnel they need quickly, and save personnel from having to physically walk around to remain visible.

    Put together, the combination of a patient advocate role, a GPS-enabled tablet and a multifunctional ER app would create a mechanism for continuous improvement by increasing feedback and recommendation opportunities, with patients commenting on their experiences, recommending ways of improving them, rating each element and their overall experience, etc.

    By implementing these processes, a hospital can move patients through in a fraction of the time while improving service and care quality with more uninterrupted time devoted to each patient.

    After implementing the changes above, the final breakdown might look something like this:

     

    Before

    After

    Necessary

    Unnecessary

    Wasted time

    Our family spent

    180

    40

    20

    0

    20

    Physician’s time

    30

    15

    10

    0

    5

    Nurse’s time

    90

    55

    40

    0

    15

    Non-medical personnel

    70

    30

    20

    0

    10

    LOW OR NO COST IMPROVEMENT IDEAS

    Here are some low cost ideas that could rapidly reduce patient frustration and perceived wait time. Investing in the following communication tools costs little money, but goes a long way towards creating patient-friendly spaces:

    · Clear signage and directionals on doors, hallways, and pathways.

    · Large visuals explaining standard operating procedures – such as what to do in an emergency, where to find the remote, how to call a nurse, etc – in every room.

    · Whiteboards where personnel can record the next procedure and estimated wait times. This may be a good practice for added redundancy and improved hand-offs, even if there is an app available – for both staff and patients.

    · Designing rooms to be more visually interesting and engaging, particularly in pediatric departments, can deliver a lot of value for little money by making patients more comfortable when they’re waiting. For example, the room my family and I were waiting in during the above story, contained a challenge that involved searching for eight dogs. This is a great example, but why stop there? Why not take it further and provide multiple non-electronic activities in each room to keep kids entertained?

    · Labeling medical devices with visual explanations of their function not only makes things more interesting for a kid stuck in a hospital room but reduces anxiety and creates educational opportunities. It also makes it easier for newer team members to orient themselves.

    · In-room visual cues about the service team should include photos and brief bios, building trust and rapport between patients and their caregivers. This could also be integrated into the app.

    · A place for recording thank-you notes, recommendations, and concerns should be available in every room.

    · The waiting room should include a play area equipped with toys as well as visually engaging and educational features.

    The following procedural improvements are also valuable and cheap to implement:

    · All personnel should be trained to greet patients, briefly introduce themselves, and explain what they will be doing and why – especially if their photo and bio are not clearly visible. This may take a few extra seconds, but establishing trust reduces anxiety and improves outcomes. A billing person should not just roll their cart in, for example, without explaining who they are or what they will be doing.

    · After finishing up with each patient, personnel should inform said the patient of what to expect next, including who will be doing it and when it will be done. Hanging a small whiteboard in every room would facilitate this kind of communication.

    · During the check-out process, patient feedback and recommendations for improvement should be collected in a structured way to help improve future operations.

    IMPLEMENTING THE ABOVE IMPROVEMENTS

    After a bit of research, it became obvious that the technological recommendations incorporated in the proposed solution above have already been developed and made available to the market for a while now.

    For example, Epic (the system Newton-Wellesley hospital, as well as many of the other medical facilities around the country already use) has modules specifically designed for app-based check-ins, and for tablet-based progress tracking and communication.

    Yet even in a clearly progressive high-quality hospital, there were many gaps. Even elements that require no technology (whiteboards, signs, improved patient and team communication, etc.) were lacking.

    This highlights why performance improvement is less about technology or processes and more about people driving positive change. Processes are important – but only if people commit to making them work.

    As a firm believer in the adage, “Convince people why they need to do things differently and they will work out how themselves,” I see the key barrier to implementation not in technology but in getting personnel engaged in organizational improvement.

    Getting highly specialized personnel to work together as a team, toward a common goal, requires the development of a set of skills and practices that are typically neglected in medical, nursing, and business schools.

    Unfortunately, most organizations do not have systems for enhancing these skills in employee onboarding and day-to-day operations. Yet, these skills — effective communication, decision making, procedure implementation, and continuous learning — can be developed with minimal on-the-job coaching and perhaps, most importantly, can be embedded into employees’ daily work processes.

    These skills not only create a better, more effective working environment, they also reduce stress and burnout and positively impact personal lives, resulting in better patient and business outcomes, lower turnover, and a higher rate of internal promotion.

    To make this transformation a reality, a good place to start is improving daily cross-functional communication. It is necessary to engage and train personnel to think in terms of process, flow, employee and patient experience, and financial outcome improvement. The best way to do this is not in the classroom, but on the floor of an ER.

    When internal employees become the agents of positive transformation, the impact is always dramatic. Systematic positive change is only possible when process reengineering is combined with engaged personnel working toward improvement, learning to collaborate more effectively, and developing cross-organizational functions.

    SUMMARY

    Healthcare is an industry ripe for dramatic breakthroughs as well as incremental improvements. Optimizing ER process efficiency for more effective resource consumption and better patient experiences can positively impact financial outcomes, reduce compliance costs and risks, and improve employee job satisfaction — a win for all parties involved.

    Technology alone, process improvement alone, or even human development alone will not get the job done. Complex problems require complex and multifaceted solutions. We can all benefit from a more effective system that produces better outcomes. Let’s work together to make it happen by implementing best practices, one facility at a time.

    AFTERTHOUGHT

    The ER is a medical environment that requires the utmost efficiency. Despite this, I was able to identify a way to double throughput and halve the variable costs of care while improving margins in just three hours of observation.

    There are many processes in healthcare that are inherently much less developed and optimized. Back-end processes, preventative medicine, public health care, and the elimination or reduction of social and environmental conditions that induce illness are by far less optimized and, particularly in pay-by-outcome environments, create opportunities to reduce the costs of care while improving margins exponentially.

    Improving patient-facing medical processes is just a starting point for the potential transformation of healthcare systems across the country and across the globe.

    Oleg Tumarkin, CEO Americas