Emergency Department H*Works Improvement Project

In 2005, we began to realize that issues, such as patients’ wait times and total lengths of stay in the Emergency Department (ED), were more than could be solved by the ED in isolation since multiple departments and disciplines directly impacted these complex matters.  Inasmuch as this endeavor would prove to be so far-reaching and multifaceted, we elected to contract with a division of “The Advisory Board,” a health care related consulting firm and think-tank from Washington DC, called H*Works.  H*Works exists to help various hospital based service lines operate at maximum potential.  Our collective goal was to streamline operations and improve patient services and satisfaction through greater efficiency.

Over the next twelve months, we closely examined work flow patterns, our collective and individual department cultures and interaction norms, and our processes for providing patient care.  What we discovered was a system that was not necessarily broken but outdated and in need of an upgrade to better accommodates higher acuities and larger patient volumes.

Phase I was to achieve buy-in for the project from management at all levels. Each Vice President was asked to champion the portions of the initiatives most closely related to the areas over which they held responsibility.

In Phase II, mapping the processes that involved triaging, registering and caring for patients in the ED who would be treated and released, was completed first. The next step in this phase was examining the steps for those patients who were to be admitted, and identifying all of the areas of the organization that impacted the process.  During a large, forum-style event, attended by leadership from across CVMC, participants began to realize how complex and arduous the processes are and how their departments and staff effect patient throughput.  The impact was astounding!  Once this realization was set, the organization rallied around this cause and readily accepted the recommendations for change.

During Phase III, areas of unnecessary segmentation and disjointed mechanics were isolated.  By aligning many of these processes so that they could take place in concert, we solved a myriad of issues and thus, corrected and/or prevented bottle necks.  For example, prior to H*Works, the simple process of getting a patient to a treatment room for examination by the provider was a series of, at least, 4 steps and could take up to an hour to complete.  Following implementation of the H*Works initiative, triage and registration are done simultaneously at the bedside.  Occasionally, the provider completes an initial assessment as the triage and registration processes are taking place.  The work accomplished is the same, simply choreographed to be more efficient.

Another process change was initiated when it was realized that there was no system in place to determine which inpatient beds were occupied or from which rooms patients had been discharged.  The solution was a simple, partially manual, partially automated system that alerts EVS as soon as an inpatient room is vacated.  When the cleaning process is complete, the AOD, who is now responsible for placing all inpatients, is alerted.  The benefits of this solution have been remarkable.  One person now acts as the clearing house and thereby can make appropriate real-time decisions based on accurate information.  The admission process, which used to require an infinite number of phone calls, and which could consume as much as an hour of a nurse’s time is now completed in a matter of minutes.  Instead of the admitted patient waiting in the ED for an inpatient room for hours while lying on an uncomfortable stretcher, within 30 minutes of the ED nurse receiving admission orders and requesting an inpatient bed, the patient is in a comfortable room upstairs; all accomplished with one phone call.

The ED has changed a great deal since the inception of the H*Works principles!  The proverbial bar has been raised and continues to be moved closer to our overall goal of patient care excellence.  Our staff, the ED physicians, nurse practitioners, and physician assistants have all come to realize the need, particularly in today’s health care climate, to not simply meet but to exceed patient expectations. Thanks to H*Works and our partnership with the entire CVMC team, these goals are within our grasp.