Administration of emergency medicine
Improving Service Quality by Understanding Emergency Department Flow: A White Paper and Position Statement Prepared For the American Academy of Emergency Medicine

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Abstract

Emergency Department (ED) crowding is a common problem in the United States and around the world. Process reengineering methods can be used to understand factors that contribute to crowding and provide tools to help alleviate crowding by improving service quality and patient flow. In this article, we describe the ED as a service business and then discuss specific methods to improve the ED quality and flow. Methods discussed include demand management, critical pathways, process-mapping, Emergency Severity Index triage, bedside registration, Lean and Six Sigma management methods, statistical forecasting, queuing systems, discrete event simulation modeling and balanced scorecards. The purpose of this review is to serve as a background for emergency physicians and managers interested in applying process reengineering methods to improving ED flow, reducing waiting times, and maximizing patient satisfaction. Finally, we present a position statement on behalf of the American Academy of Emergency Medicine addressing these issues.

Introduction

Emergency Departments (EDs) have experienced dramatic increases in patient volume over the past decade (1, 2, 3, 4, 5, 6, 7). In June 2006, the Institute of Medicine released the landmark study titled, “Hospital-Based Emergency Care: At the Breaking Point” (8). The report described the national epidemic of ED crowding and discussed the systematic problems with patient flow in hospital EDs. The crisis of crowding is one of increases in volume along with reductions in overall system capacity. From 1992 to 2003, annual ED visits increased from 90 million to 114 million, whereas the total number of EDs declined 8.1% over the period of 1994 to 1999 (9, 10). Although there are many proposed definitions for ED crowding, there is still no clear consensus on a generalizable operational definition in order that levels of crowding may be compared between hospitals. In the simplest sense, ED crowding occurs when a health system's supply of emergency services becomes overwhelmed (1). The mismatch of demand and supply for service affects the ability of emergency physicians and their emergency care teams to deliver effective care (1, 11). The increased demand on the ED stretches its abilities to provide efficient, consistent, and cost-effective care while at the same time attempting to keep patients satisfied and avoid malpractice risk. Given that many EDs commonly experience crowding today, emergency physicians, management, and staff must seek ways to meet these challenges or face losing their patient base, providing unsafe or substandard care, losing staff, or risking financial integrity.

ED crowding can affect all aspects of patient care, from clinical quality of care (i.e., time to antibiotics for community-acquired pneumonia or timing to percutaneous intervention for patients with ST-segment elevation myocardial infarction) to service delivery quality. Service quality delivery is the patient's perspective on the quality of their experience; this is determined by waiting times, staff interactions, symptom control, perceived quality of medical service, and overall communication. Although there are only a modest number of studies exploring the crowding–quality link, recent studies have shown clearly that wait time directly affects patient satisfaction (12, 13, 14, 15, 16, 17, 18, 19). Time to evaluation can also influence whether or not a patient is seen at all (12, 20). This is important for patients with potentially serious, undiagnosed conditions who are discharged and told to return in case of worsening symptoms.

Waiting times are directly affected by availability of inpatient beds (21). When demand for inpatient beds outstrips supply, admitted patients are often forced to wait in the ED. In many health systems, the ED serves as a waiting area for hospital admissions that originate both in the ED and in private doctors' offices. When admitted patients board in the ED (especially when no resource support is sent along to help with admitted, boarded patients) the ability of the ED staff to evaluate and treat new patients while caring for those boarded is severely reduced. One solution that has been suggested for this is allowing admitted patients with bed assignment to board on floors while beds are being cleaned. This strategy might improve ED boarding times for inpatients and help relieve ED crowding.

In 2003, the US General Accounting Office released a 2-year study that found that the inability to transfer patients to inpatient beds was most commonly associated with crowding (22). Whereas in the early 1990s crowding was confined to large, city hospitals, it has now become pervasive in community EDs (2, 23). Other factors that contribute to ED crowding include the increased complexity of ED diagnosis and treatment, availability of timely consultation, the lack of appropriate funding for Emergency Medical Treatment & Labor Act-mandated care, increasing numbers of uninsured patients, workforce shortages (especially nursing), and deficiencies in preventive care for millions of Americans (4, 6).

Following on the heels of its first two reports: “To Err Is Human” and “Crossing The Quality Chasm,” the Institute of Medicine, with the National Academy of Engineering, has just released its third report: “Building a Better Delivery System: A New Engineering/Health Care Partnership.” Modeling and simulation using queuing methods and discrete-event simulation head the list of systems-analysis tools recommended in this latest report. Engineers use systems-analysis tools to help themselves and others understand how complex systems operate, how well systems meet overall goals and objectives, and how they can be improved.

On behalf of the American Academy of Emergency Medicine (AAEM) throughput committee, we have sought to provide emergency physicians and managers with a background on the ED as a service business and an overview of some of the latest technology on process reengineering that can be practically applied to EDs. Table 1 provides an overview of the business concepts described in this article. Our goal is to provide ED managers a basis for understanding the ED as a service business, describe how to capture the process of flow through the ED, and provide the AAEM position statement on improving service quality by understanding ED throughput.

Section snippets

Manufacturing vs. Services

A manufacturing business and a service business are different in fundamental ways. Manufacturing is characterized as the making of goods or articles by hand or machinery, with finished goods inventory as the output. By contrast, services, and service delivery settings like an ED, are different. Manufacturing and services diverge with regard to the following concepts: intangibility, inseparability, personal relationships, their simultaneous creation and consumption, the customer (patient) as a

Rethinking Management in Emergency Medicine: To Process and Systems Thinking

Many industries have moved to a process and systems way of thinking about, measuring, and managing business processes. Instead of focusing on individual events, the entire system is analyzed and key choke-points (“bottlenecks”) are identified (26). Process flow can be analyzed by using the many techniques taught by systems engineering and the discipline of operations management (industrial engineering). Examples of recent outgrowths from these established disciplines are the Lean and Six Sigma

Understanding Gridlock

To better assess the degree of gridlock that an ED suffers, specific measures can be utilized for magnitude quantification. These measures allow for comparison between EDs and allow for assessment of change initiatives. Solberg et al. developed a set of metrics that allow for analysis of this ED gridlock (27). Those factors that affect demand for ED services are the input measures; ED efficiency impacts throughput measures; and hospital inpatient, post-discharge care and ambulatory care systems

Demand Flow Management

Demand flow management is about predicting (forecasting) demand and then acquiring and deploying/scheduling all of the resources required to meet that demand. Demand and capacity matching happens in services through demand forecasting and then matching resources to predicted demand states. By predicting demand, we forecast the services that will most likely be requested. We can then make resource scheduling decisions to optimize flow. This is how one goes about capacity planning in any service

Critical Pathways

Critical pathways or treatment protocols are an effective strategy to reduce variability in care and ensure that patients receive standardized therapies that have been shown to improve outcomes. For example, McGarvey and Harper found that standardizing a critical pathway for pneumonia care reduced overall time to antibiotics, improved blood culture draws before antibiotics, and decreased hospital length-of-stay for pneumonia patients (29). By reducing the variability of care for a given

Understanding Process: Process-Mapping and Workflow-Diagramming

Process-mapping (also known as flow-charting or activity-sequencing) is used to improve understanding of how a specific type of work process occurs in the ED. Through flow-charting a specific process, several things are accomplished. It allows visualization of the work process and all of the specific steps that are performed in an organization are considered. Mapping promotes a “why do we do it this way?” way of thinking. Mapping can facilitate collaboration between different staff types and

The Emergency Severity Index Triage System

The Emergency Severity Index (ESI) is an ED triage algorithm that provides clinically relevant stratification of patients into five groups, from 1 (most urgent) to 5 (least resource intensive) on the basis of acuity and resource needs. Benefits of a successful ESI implementation include improvements in ED operations, support for research and surveillance, and a standard metric for benchmarking. Specific operations management opportunities that become available after the implementation of ESI

Bedside Registration

Patient registration has been cited as a major delay to care. Although necessary for both ensuring reimbursement for services provided and maintaining the integrity of the medical record, registration of ED patients is a time-consuming, labor-intensive, and often redundant process (32, 33, 34, 35). One recent study cited expediting registration as the third most effective way to reduce patient wait times, trailing only creating a “top institutional priority combined with physician-led

The Lean and Six Sigma Business Management Methods

Lean is an effective business improvement methodology that is commonly used in manufacturing (38, 39). These principles have been applied to hospital services delivery and have been reported to be highly successful in the ED setting and the inpatient setting in case reports in peer-reviewed journals (40, 41, 42, 43). Therefore, these methods may have the potential to improve both the efficiency and quality of care delivery systems. The goals of the Lean business improvement method are to make

Forecasting Demand: Statistical Forecasting

Statistical forecasting is an operations management method that uses time series data and a variety of statistical formulae to forecast, mathematically, different types of events (46). Once you have acquired some “rate of incoming” data by hour of the day and day of the week from your registration system, if ESI triage has been up and running for a period of time and you have collected ESI case mix data, or if you have an ED Information System in place that archives important operational data,

Queuing Systems

A queuing system consists of arriving customers (entities) and one or more servers providing service of some kind to these arriving customers. When customers arrive to find all servers busy, they usually join one or more queues (lines) in front of a server. A queuing system can be characterized by three components. The first is the arrival process, or how entities arrive to the system. This is best characterized by arrival rates (= arrivals over time), that is, arrival distributions. The second

Discrete Event Simulation Modeling

Discrete event simulation models are able to explicitly represent variability, interdependencies, and complexity in a computer representation of a system. As a result, it is possible with a simulation model to predict system performance under varying inputs (loads), compare alternative system designs, and to determine the effects of alternative policies on the performance of a system. The types of system service performance metrics include: resource utilization rates; queue number, length and

Balanced Scorecards

The balanced scorecard is a management system initially developed by Drs. Robert Kaplan and David Norton at the Harvard Business School (48). The balanced scorecard provides continuous feedback to leaders on internal management processes and outcomes to improve system results. In contrast to the traditional model of quality assurance in health care, where a problem is identified when there is a medical error or poor outcome is recognized, the balanced scorecard provides continuous monitoring

Implementation of a Workflow Solution

Once the key processes have been mapped and bottlenecks identified, this information must be conveyed to senior management. The way one proceeds with conveying this information to the hospital's key stakeholders can be as important, if not more so, than the actual information regarding the critical bottlenecks in a workflow. Without gaining initial support for a change initiative, little can be accomplished; administrative buy-in is crucial.

Although often overlooked, identifying and targeting a

Conclusion

ED crowding is a national problem. Managing inputs, throughputs, and outputs in the ED is critical to providing high quality emergency care. There are many ways to improve throughput in the ED. It is currently unknown which strategies provide the best solution to fix throughput in the ED. Because each ED is different, the correct strategy must be tailored to the problems and issues in each specific ED. There is no “golden fix” for ED crowding, nor is there a universal definition for ED

Disclaimer

This White Paper represents the position of the authors and has been approved by the Board of Directors of the American Academy of Emergency Medicine. The opinions and views herein do not necessarily represent the opinions of the Journal of Emergency Medicine.

AAEM Position Statement

On behalf the American Academy of Emergency Medicine, this position statement has been approved by the Board of Directors:

  • 1

    It is the mission of emergency medicine to provide continuous access to board-certified emergency physicians to provide high quality care for patients with emergent and urgent conditions.

  • 2

    Emergency Department (ED) crowding is a national problem that affects the quality of health care for every American because it limits the continuous access to high quality care.

  • 3

    ED crowding

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