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ED slashes average wait time by more than an hour
Team studies facilities, creates own model
No ED cuts its average door-to-doc time from 93 minutes to 20 minutes by accident. The success story at Memorial Hermann Memorial City Medical Center in Houston was the result of discovering a patient flow model at another facility that was superior to theirs, and then continuing to search out additional models to come up with their own system that best addressed their specific needs. The result was a model they call ExcelERate, which includes a more detailed nurse assessment up front, parallel processes, and the carving out of an intake area within the ED.
"We reoriented our entire space, putting dividers screens in four rooms to duplicate our capacity," explains Michele Bell, RN, MBA, chief nursing officer at Memorial Hermann. The department now has 10 intake and procedure rooms; five continuing care rooms with stretchers; four rooms with two recliners each, separated by curtains, with 13 spaces for continuing care and 13 acute care beds; and an overflow room that has 10 chairs.
The changeover began when Jim Parisi, RN, Memorial Hermann Healthcare System executive of emergency services, went to Phoenix to visit Banner Estralia Hospital at the invitation of its client, Cerner. Banner Estralia was using Cerner IT systems and had gone paperless. "We took a tour of the hospital that in started in the ED — and we just stayed there," he recalls.
What impressed Parisi was that the busy ED (60,000-70,000 visits a year) "seemed so well organized and relatively quiet." He started asking lots of questions, and when he came home, he met with TeamHealth, which provides ED coverage for the system. "We agreed that while this would not do everything for us, their 'split-flow' process had the most chance of anything we had seen to help us," says Parisi.
Then, a team that included physicians, nurses, and representatives from the lab, radiology, and administration visited the Banner facility. "As an interdisciplinary team, they had to envision how this would work in our physical plant," says Parisi.
Children's hospitals toured
The research didn't end there, says Bell, who joined the team on the Phoenix trip. "We also saw several children's hospitals in Cleveland, because we will be putting in a children's ED in June, and then we kind of combined the best of all the models," she notes.
Because the staff already had had extensive experience with Six Sigma methodology, the conversion process also was facilitated by Black belts and Green belts, "so we knew we could show measurable improvement," says Bell.
That they have accomplished: Parisi says the left-without-treatment rate had been as high as 9%-10%, "and now it is way less than 2%." That improvement, adds Bell, also is reflected in the department's Press Ganey patient satisfaction scores. "We started in very low digits and now run anywhere from 80 to 95," she reports.
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'Quick look' starts rapid flow process
The ED at Memorial Hermann Memorial City Medical Center in Houston has slashed its door-to-doc times from 93 minutes to 20 minutes with the help of an internal process it calls ExcelERate. The process begins with a "quick look," explains Jim Parisi, RN, Memorial Hermann System executive of emergency services.
"The nurse will just ask the patient their name, their age, and what's bothering them," he explains. "If it's an acute problem, like chest pain, you are taken to the back, just like in our old model."
For less serious cases, however, the ED has created an intake area. There, the nurse completes the assessment, and the doctor comes in shortly thereafter. "Since the doctor sees the patient faster on the front end, they can order more labs right then," says Parisi. "If the patient has mild abdominal pain — for example, the doctor orders lab, IV, maybe an X-ray — but instead of staying in that bed, they go to 'continuing care,' where they wait for the labs to come back and prepare for discharge directly."
Staffing critical to help speed flow
When the ED at Memorial Hermann Memorial City Medical Center in Houston was preparing to implement its new flow model, ExcelERate, it was clear that the revised ED processes could not be run by just anyone, says Michele Bell, RN, MBA, chief nursing officer at Memorial.
"The ED brought in six coordinators — RNs — who are on 24/7," she says. "They are the best nurses." These individuals, she notes, are responsible for keeping the rest of the staff and the lab moving. They are constantly running to the front and checking the waiting room as well, because, Bell says, "I want it empty all the time."
Speed is the toughest part of the model, she says. "The staff voted on their strongest leaders who they thought could do this model," Bell says. The entire ED staff are evaluated on three metrics: turnaround time, door-to-doc time, and customer satisfaction. "They can earn up to an additional 2% of their salary," she says.
Not every staff member was thrilled with this new approach, Bell concedes. "We lost a lot of them and replaced them," she says. "There are some people you just know are not going to change."
For some staff, however, it was just a case of needing to see the model in operation. "The nursing director for the ED was dead set against it at the beginning," recalls Bell. "It's very hard for an ED nurse to focus on treating people quickly."
However, she says, that nurse manager now is "very proud of our performance."