Title: A major Northeastern Academic Medical Center requested that Maverick Healthcare Consulting analyze a
1February 7, 2003
Boston, New York, Miami, Houston, Atlanta
A Maverick Healthcare Consulting Group Case
Study Emergency Department Turn-Around
- A major Northeastern Academic Medical Center
requested that Maverick Healthcare Consulting
analyze and evaluate its Emergency Department
(ED) operations and process flows and assist in
the development and implementation of improvement
recommendations. As a regional tertiary referral
facility with a designated Level I Trauma Center,
the client ED treated over 75,000 annual adult
and pediatric emergency patients. Approximately
65 of the hospitals admissions came from the ED.
Additionally, because the client was located in
a densely populated urban setting, it was the
states largest provider of services to the
Medicaid and Charity Care population. - Major objectives of this engagement were to
- Achieve compliance with state requirement that
all patients receive medical screening exam
within 4 hours of presentations - Reduce patient average wait time and average
length of ED stay - Reduce bypass and diversion hours resulting
in increased ambulance traffic and ED admissions - Improve capture of front end financial data
resulting in increased collections from
commercial, governmental and charity payers - Improve patient and employee satisfaction
Healthcare Consulting Services
2Maverick Healthcare Consulting Case
Study Emergency Department Turn-Around
Page 2
The Symptoms
- Upon initiation of the improvement initiative,
Maverick Healthcare Consulting consultants
conducted a series of physician and
administrative interviews coupled with high level
data analyses, process observation and mapping to
determine a performance baseline.
Characteristic identified during this initial
evaluation included - Chronic patient gridlock from late morning to
late afternoon - Excessive patient wait time around the clock
- Over 10 of the patients did not receive a
medical screening exam within 4 hours of
presentation - Over 8 of the patients left before completion of
service - Significant monthly Bypass with the ED closed
to EMS ambulances over 60 hours per month,
generally during high demand periods, resulting
in declining hospital admissions and net revenues - Insufficient documentation of care provided
resulting in significant under-coding and lost
revenues - Clinician and physician burnout, apathy and
entrenchment - Excessive patient complaints to hospital
administrators, city and state government
officials
Maverick Healthcare Consultings implementation
capability makes them uniquely valuable. They
delivered significant bottom line improvements
within one year focused more on revenue
enhancements than cost cutting. They also
applied creativity, insights and persistence in
fundamentally repositioning our medical schools
and hospital. EVP - Administration and
Finance Academic Medical Center
3Maverick Healthcare Consulting Case
Study Emergency Department Turn-Around
Page 3
The exhibit above provides a graphical
illustration of the typical patient flow,
physician staffing and productivity and 95
confidence wait times (average plus 2 standard
deviations) over a 24 hour period during the
baseline analysis. The purple bars represent the
number of patients presenting in the ED each half
hour across the period. The blue line represents
physician/advance practice nurse staffing levels.
The green line represents average MD/APN
productivity in terms of patients treated per
hour. The red line represents expected waiting
time at the 95 confidence level (average wait
time plus two standard deviations). As is
illustrated in the exhibit, physician
productivity generally mirrors patient arrival
rates from 1000 pm through approximately 1000
am. Direct observation and data analysis
confirmed that despite lower physician staffing
levels during this period, patient flow through
the ED was maintained and patient volume did not
exceed capacity during this period. As patient
volume grew through the morning, physician
staffing increased slightly and productivity
increased to its peak of nearly 4 patients
treated per MD or APN per hour, or twelve total
patients treated per hour. In essence, although
wait times were significant, the system did not
generally become encumbered and service was
maintained and even enhanced as volume grew. The
period from approximately 1000 am to 1000 pm
presented a very different picture. Patient
throughput declined significantly to less than 8
patients treated per hour, and despite increasing
the number of MD/APNs to as high as eight
practitioners on duty, physician productivity
declined to less than one patient treated per
practitioner per hour. With approximately ten
patients presenting per hour, significant
backlogs of untreated patients developed ,
resulting in the negative symptoms described
above. ED personnel typically suspended or
dramatically reduced fast track services,
giving treatment precedence to more acutely ill
patients. Backlogs of patients in the ED waiting
for admission to the hospital developed and
practitioners were compelled to shift efforts
from treat and release of emergency patients to
maintaining sicker patients in the ED rather than
in more appropriate routine or critical care
inpatient settings. As gridlock intensified
through the afternoon and early evening, it
became necessary to frequently declare a bypass
situation, causing EMS to divert ambulance
patients to other settings. ImPart Group
consultants worked with hospital financial
personnel to determine that the decline in volume
combined with the ineffective use of emergency
resources was costing the organization between
1015 million per year in lost revenues and
excess staffing expenses.
4Maverick Healthcare Consulting Case
Study Emergency Department Turn-Around
Page 4
Identifying the True Problem Drivers
- Because of the magnitude of the problem, in terms
of both its financial and quality of service
impact, hospital leadership demonstrated a very
strong desire and commitment to identify and
correct the underlying forces that were causing
the negative symptoms to occur. Maverick
Healthcare Consulting was given the authority to
form multi-disciplinary work groups of hospital
personnel to perform detailed process and
workflow analysis to identify the real factors
that were causing the negative symptoms to occur.
The work groups formed included ED personnel as
well as staff from a variety of operational
departments that routinely interacted with the
ED, including Admitting and Registration,
Radiology, Laboratory, Routine and Critical Care
Nursing, Medical Records, Transport,
Environmental Services and selected Medical and
Surgical Services Physician leaders. Detailed
analysis of all key process flows and
interrelationships identified not just few, but a
very significant number of underlying problems
that interacted in a complex way to cerate the
situation described above. The underlying
problems were grouped into two basic categories
those problems that originated in the ED, and
those that originated in other hospital operating
departments and were therefore beyond the control
or impact of ED personnel. Problems identified
as internal to the ED included - Insufficient ED Management The ED had been
operating without an administrative Director for
a number of years. The physician in charge of
medical operations had been covering this
function, however with the responsibilities of
managing the medical leadership of a Level I
Trauma facility, combined with the requirements
of operating an emergency medicine residency,
medical leadership had little time to devote to
the operational management of the department. - Ineffective Core Processes Key processes
required for effective ED operation including
triage, intake, registration and patient flow
management were ill defined and inconsistently
followed. Performance monitoring and feedback
tools did not exist. - Ineffective Documentation Process and Formats
All patient care documentation was in the
narrative form. This resulted in significant
variation in documentation from practitioner to
practitioner and resulted in significant
legibility problems for Medical Records
personnel. Additionally,, as ED volume increased
to chaotic levels, thoroughness of documentation
declined resulting tin a variety of financial
liability and quality of care issues. - Insufficient Use of Leveraging Technology At
the time of the study, the ED was essentially a
manual shop. Typical technology enhanced
applications such as bedside registration,
point-of-care testing, automated discharge
instructions and automated patient management
were not employed. - Insufficient Physician Leverage Initial
hospital efforts to relieve identified symptoms
were focused on increasing the compliment of
physicians and advanced practice nurses available
to care fore patients. At the time of the study,
the number of MDs and APNs exceeded that of RNs,
techs and other support personnel. This often
resulted in a classic situation of idle
practitioners due to lack of support to turn
treatment space, restock supplies, transport
patients, etc. - Employee exhaustion, entrenchment and low morale
As a Physician at an Academic Institution who
has dealt with a host of experts working with
this Firm has been a breath of fresh air. They
were competent, logical and reality-based. Their
ability to understand complex issues and to help
implement solutions that address the issues of a
teaching hospital was nothing short of
remarkable. Chief of Surgery Academic Medical
Center
5Maverick Healthcare Consulting Case
Study Emergency Department Turn-Around
Page 5
Identifying the True Problem Drivers
continued..
- Many of the previously mentioned issues did not
come as a surprise to hospital leadership.
Despite the fact that they had been previously
discussed as issues that had a negative impact
on ED operations, lack of departmental management
, lack of process redesign experience and the
ongoing necessity of responding to increasing
patient demand with limited personnel and
resources prevented the hospital from making
significant progress in improving the situation.
Less expected by hospital management was the
impact that departmental operations external to
the ED had on the situations. External forces
that helped drive the ED dysfunction included - Diagnostic Service Turn-Around Time As the ED
patient volume, and its corresponding need for
diagnostic radiology and lab services, peaked
during late morning and early afternoon, demand
for diagnostic services from other hospital
inpatient and ambulatory departments also peaked.
Analysis of diagnostic capacity vs. demand
indicated significant capacity shortages
throughout peak operating periods. - Lack of Available Inpatient Beds As was the
situation with diagnostic services, demand for
inpatient beds typically peaked in the early to
late afternoon. Unfortunately, due to a variety
of factors including lack of a functional
integrated discharge planning function, residency
program conflicts, and a lack of effective bed
management and communication processes,
significant patient discharge activity did not
typically occur until later in the afternoon or
early evening. As a result, emergency department
admissions were forced to compete with scheduled
admissions and the PACU for patient beds
throughout peak service periods. - Excessive Specialty Consult Wait Times Often
requiring 3 or more hours for on-site specialists
to perform consults and assist in defining
treatment regimen and/or make admission
decisions. - Departmental Silos Inhibited
interdepartmental communication and
functionality. - The detailed analytical activities performed
demonstrated to management that it would be
necessary to make investments and extend the
scope of the redesign effort well beyond the
internal operations of the ED if a positive and
sustainable improvement was to be achieved.
Additionally, prior to instituting corrective
actions, these finding were discussed thoroughly
with physician and administrative leadership
throughout the organizations. Care was taken to
correctly represent the issues as process
complexities that had evolved in response to
systemic pressures, rather than inadequacies
inherent in any single operational area. Each
participant was helped to understand how life
would be better for them if the processes were
improved and a grass roots commitment to
correcting the situation was developed across the
institution.
6Maverick Healthcare Consulting Case
Study Emergency Department Turn-Around
Page 6
Investing in the Solution
- Having developed physician and administrative
leadership alignment regarding what must be done
to improve ED operations, and an estimate of the
significant positive financial impact related to
doing so Executive Management was prepared to
make the necessary investments for a successful
turnaround. Managements vision and commitment
resulted in the following investments over
approximately a twelve-month period - Hiring an Executive Director to lead ED
operations and restructuring of the ED
supervisory structure - Redesign of major core processes including
triage, intake and registration - Additions of key leveraging personnel, including
RNs, Techs, and assorted support personnel within
the ED and other process-linked hospital
departments - Implementation of technology improvements
including bedside registration, automated
discharge instructions, automated communications
technologies, etc. - Implementation of template-driven documentation
improvements and increased functional integration
with Medical Records and Patient Accounting - Implementation of point-of-care testing
technology - Purchase and installation or required radiology
equipment - Development of integrated care management and
resource utilization guidelines and protocols
among Radiology, Pathology and Emergency Medicine - Physical redesign of existing ED space and the
addition of incremental required space. - Because of their involvement in the diagnostic
phase of this initiative, and because of the
addition of experience full time ED
administrative leadership just prior to the
investment phase, client personnel were able to
lead most of the investment activities described
above. Consultants from Maverick Healthcare
Consulting assisted in the creation of project
direction and work plans, and coached client
personnel in necessary change leadership and
technical design activities required to achieve
success. In this way, client capability and
competence is developed as the solutions are
conceived and implemented.
7Maverick Healthcare Consulting Case
Study Emergency Department Turn-Around
Page 7
Results
- At this point, our client views improvement as a
continuous process one where opportunities for
improvement are constantly sought and new
initiatives instituted as prior initiatives
achieve success. Results approximately one year
after initiation of ED improvement solutions
include - Reduced patient wait time and ED ALOS
- Reduced walkouts
- Reduced Bypass from a pre-initiative level of
over 60 hours per month to a current level of
less than 10 - Increased patient volume and ED admissions
- Increased thoroughness and consistency of
documentation, and resulting increase in net
revenue collected - Improved capture of patient financial
information. - Client financial personnel estimate that economic
impact of improvements to date is in the 5 to 7
million annual range, and expectations are that
further improvements will boost the impact to
exceed 10 million annually.
8Maverick Healthcare Consulting is a healthcare
consulting organization composed entirely of
senior healthcare industry professionals.
Evolved in 2007 by executives from major national
consulting and multi-hospital academic medical
center organizations, Maverick principals have
assisted Academic Medical Organizations, Medical
Schools, Physician Group Practices, and Health
Plans to design and implement significant lasting
improvements in quality, operational
effectiveness and operating margins. We do not
subscribe to the highly leveraged model of
consulting. Instead, our seasoned executives
work directly with your leaders and staff to
thoroughly diagnose the situation at hand, build
organizational consensus regarding the most
appropriate course of action, and then work
side-by-side with your people to develop and
implement solutions that are right for your
organization and competitive environment. In the
process, we build honest, informal and highly
productive working relationships that enhance the
skills, capabilities and confidence of our client
personnel. Our clients tell us that not only are
we experts at making the right things happen,
but that we typically do so in less time and at
less cost than other major consulting
organizations. For more information regarding how
Maverick Healthcare Consulting can assist your
organization, please contact Scott Hodson,
Principal shodson_at_MavHC.com Rick Smith,
Principal rsmith_at_MavHC.com Terry Carrol,
Principal tcarrol_at_MavHC.com
Atlanta Cape Cod Miami Omaha