The Definitive Guide to Emergency Department Operational Improvement

Employing Lean Principles with Current ED Best Practices to Create the “No Wait” Department, Second Edition

Jody Crane, MD, MBA, Chuck Noon, PhD

• Publisher: Productivity Press
• Year: 2019
• Print ISBN: 9780367432331
• eBook ISBN: 9781498774536
• Edition: 2
• Topic: Business
• Subtopic: Management
• Index: Business

This revised and updated book explores the academics behind managing the complex service environment that is the Emergency Department (ED) by combining applied management science and practical experiences to create a model of how to improve operations. This book offers a presentation of Lean tools used in the ED along with basic and advanced flow principles. It then shows how these concepts are applied and why they work, supported by case studies in which Lean principles were used to transform an underperforming ED into a world-class operation. After reviewing best practices, the authors explain how to achieve excellence by discussing the elements of creating a culture of change.

Chapter 1

Introduction to The Definitive Guide to Emergency Department Operational Improvement

Since the first writing of this book nearly a decade ago, emergency medicine and, indeed, all of healthcare has been under the microscope due to increasing spending and the mounting pressures of government reform. The prevailing movement recently has been towards population management and away from fee-for-service; although 95% of healthcare expenditures for outpatient visits today are fee-for-service payments (Health Affairs, March 2016). While the future financial directions of healthcare are unclear today, most experts agree that the rate of spending on healthcare must abate. Most point towards inpatient and post-acute care, the most expensive elements of healthcare, as the most potentially impactful targets.

Perhaps the most comprehensive work written on the current state of healthcare that has had the greatest impact is the Institute of Medicine’s (IOM) The Future of Emergency Care in 2006. Other noteworthy sources of the current state of emergency medicine include the American College of Emergency Physicians’ (ACEP) National Report Card on the State of Emergency Medicine, the Centers for Disease Control and Prevention’s (CDC) The National Hospital Ambulatory Medical Care Survey (NHAMCS), and the Centers for Medicare and Medicaid Services’ (CMS) Hospital Compare website.

Institute of Medicine Report ¹

The IOM’s Hospital-Based Emergency Care: At the Breaking Point is perhaps one of the most politically important recent publications because it has drawn so much attention to the frailty of our emergency medical system. This report is important to emergency medicine because the IOM looks at emergency medicine from a global and comparative perspective. Therefore, the report is unbiased with no self-serving point of view and tailored toward emergency medicine practitioners. Additionally, it was authored by some of the most respected professionals in the field of medicine, who contributed knowledge, time, and effort to create a three-volume report that was as accurate as it was comprehensive.

The key findings of this report center around overcrowding, the fragmentation of the emergency medical system, the lack of specialists, lack of disaster preparedness, and insufficiency of the pediatric system in terms of equipment and supplies in emergency departments (EDs) that do not specialize in pediatrics.

The IOM report is comprehensive, detailed, and explicit in both its analyses and recommendations and is a great snapshot of the existing state versus the optimal state with respect to emergency services in the United States. Their recommendations will be discussed later in this chapter.

The National Hospital Ambulatory Medical Care Survey: 2014 ²

The NHAMCS survey is published periodically by the CDC. It is an excellent source of general data about patients who are treated in EDs all across the country. It has excellent national data on patient demographics, volume and throughput statistics, payer mix, ancillary utilization, and patient flow. Since 2010, the CDC stopped publishing summaries and now only publishes summary data tables. Nonetheless, it is an excellent source for national statistics and ED visits.

The American College of Emergency Physicians’ State of Emergency Medicine National Report Card ³

ACEP’s National Report Card on the State of Emergency Medicine is a report published every 5 years that assesses each state’s support for emergency services. It is intended for politicians in terms of directing healthcare policy and financial decisions. In this report, each state is graded in six areas: Overall, Access to Emergency Care, Quality and Patient Safety, Medical Liability Environment, Public Health and Injury Prevention, and Disaster Preparedness.

The report highlights the inadequacies in our healthcare system and enables users to compare their state with other states, as well as rank where they stand nationally in each category. While the report frequently generates much publicity when it is released, it does make some providers uneasy as it could be interpreted to mean that their care is inadequate. However, the goal of preparing this report is to help ED physicians present their case to lawmakers and to lobby for increased state and federal support for emergency services.

Center for Medicare and Medicaid Services (CMS)

An important goal of the government’s push towards meaningful use and value-based purchasing is achieving true transparency with respect to quality, operational, and patient experience data. Hospitalcompare.gov achieves this goal by publishing aggregated hospital data in all three of these areas. Not only is the site publically accessible and searchable, but the results are driving Medicare’s Star Ratings System.

The remainder of this chapter will discuss, in more depth, specific topics taken from the publications previously introduced, other reports, and public opinion as presented in the news, to summarize the current state of emergency medicine. All of these reports are a testament to the problems faced by the emergency medicine profession and industry. As of the most recent NHAMCS data published for the year 2014, ED visits have reached an all-time high of more than 141 million visits annually, up from 119 million visits when we first published this book in 2011. This is one visit for every 2.3 people living in the United States.⁴ Hospital overcrowding has pushed the typical ED beyond overflow levels, limiting the number of ED treatment beds due to inpatient bed shortages. It is important to note that recent trends in reducing government payments for inpatient services is fueling a phenomenon whereby, anecdotally, the most common context of boarding is with vacant licensed—but unstaffed—inpatient beds. While this inpatient bed closure may be due to labor shortages, efforts at cost containment, or declining profitability of inpatient care, in most cases this is not a physical inpatient space constraint but more likely a financial, policy, or mind-set constraint.

The ability to provide ED services is affected by shortages in ED physicians, nurses, and ancillary staff members like ultrasound and computed tomography staff. Such shortages threaten the framework of emergency medicine. The cumulative result of these factors has negatively impacted the quality of patient care. Delays and treatment errors are rising because providers are required to see more patients in less time. Additionally, more patients seen equates to more beds utilized. This has a cascading effect in the waiting room; waits increase until beds can be turned over and many of those patients waiting have potentially life-threatening problems!

Again, these occurrences expose hospitals to liability and medico-legal issues. Some hospitals have even experienced delays that have ultimately led to patient death due to their inability to see a provider in a timely manner. A few stories about unnecessary deaths in the ED have played out in the news, but most such episodes never reach the public.

The current state of emergency medicine is far from optimal in the eyes of many colleagues, friends, and most major emergency medical organizations. In fact, many of our colleagues are actively dissuading their children from pursuing careers in emergency medicine. The only way to change this direction is to actively engage in the solution. This must involve rooting out waste and creating value for our ...

Table of contents

• Cover
• Half-Title
• Title
• Copyright
• Contents
• Preface
• Acknowledgments
• Authors
• 1 Introduction to The Definitive Guide to Emergency Department Operational Improvement
• 2 Value Stream Mapping
• 3 Standard Work
• 4 5-S Workplace Organization
• 5 Inventory Management Basics
• 6 Rapid Changeover
• 7 Mistake Proofing
• 8 Lean Flow
• 9 ED Flow as a Network of Queues—Matching Demand and Capacity
• 10 The Lean ED—Lean Applications in a 100,000-Visit Emergency Department
• 11 Best Practices—The Door-to-Doc Interval
• 12 Best Practices—Doc-to-Disposition Interval
• 13 Best Practices—The Dispo-to-Departure Interval
• 14 Patient Experience
• 15 Leadership and Change Management in Healthcare
• 16 Design of the Lean ED
• 17 Case Studies of Operational Improvement in the Emergency Department
• Index