Why It Matters
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I used to work in an emergency department (ED) in Sacramento, California. We started out with a volume of 67,000, but in about five years it went up to 130,000. Working there felt like chasing a moving train all the time.
Then the nursing director and I attended a lean operations course that helped us see what we were doing — especially around workload and staffing — in new ways. In about two years, we developed an emergency department that was performing in the 99th percentile of the country.
How did we do it? Instead of using the one-size-fits-all approach many hospitals use — that we, in fact, had been using for years — we started considering how long it takes to care for each patient and matching staffing with demand.
Using a cookie-cutter approach to improve patient flow doesn’t work because there are so many kinds of emergency departments. Emergency departments are small, medium, or large. There are high-acuity emergency departments that require a lot of nursing resources. There are also those with lower acuity that can manage with fewer nurses. You have to look at the acuity of your hospital, the acuity of your emergency department, and consider what kind of patients are coming through the door.
In my years working on patient flow, I’ve encountered a number of myths and misunderstandings. It’s worth addressing a few of them here:
- The nurse-physician partnership is crucial. People often underestimate the importance of the nurse-physician partnership throughout the emergency department. When I first started figuring out how to redesign ED flow, learning and working with our nursing director was crucial. If I hadn’t had him as a partner, I don’t think our efforts would have worked. For direct patient care, this same partnership is also crucial. Having nurse-physician care teams working together improves quality, decreases length of stay, and evens workload for both physicians and nurses.
We prioritized two things: 1) How could we give excellent patient care? 2) How could we make it easier for the people doing the work? We didn’t want nurses to worry that they couldn’t give excellent patient care. We also wanted to match nursing staff with demand and have our efforts work financially for the organization. With our shared goals and priorities to guide us, we worked together on solutions. - Cutting nursing staff doesn’t save money. Another common misconception is the idea that decreasing staffing saves money. In fact, we often find that when you decrease nurses, flow completely falls apart. It’s essential to do a risk-benefit analysis when you’re staffing your emergency department. Is the cost of one nurse worth possibly increasing adverse events in the waiting room? Is it worth patients leaving without being seen? Is it worth damaging your organization’s reputation in the community?
LEARN MORE: IHI Hospital Flow Professional Development Program
- ED arrivals are predictable. A lot of people think that emergency department arrivals are unpredictable, but the reality is that they’re even more predictable than an OR schedule. Kurt Jensen is an expert on improving hospital flow. When he talks about flow in the emergency department, he likes to say, “We know patients are coming; we just don’t know their names yet.” It’s important to look at staffing through every hour of the day, day of the week, and month of the year to make sure you’re matching staffing with patient arrivals.
If you have a high-volume department, the variation in arrivals is very narrow. It might vary by day of the week or month of the year, but it will vary predictably. Medium- and low-volume departments have a little more variation, but will, again, vary predictably.
Before I started to learn more about queuing theory, I didn’t realize there are predictable arrival patterns into an emergency department. For example, in many places 3:00 PM is an especially busy time of day in the ED. Flu season is a predictably busy time of the year in the ED. Staffing appropriately can reduce wait times and patients leaving without being seen. It can increase patient and staff satisfaction as well as providing financial benefit to the organization. Appropriate staffing is a growth strategy, not a contraction strategy.
- Flow-based systems provide the right care efficiently. Often, the places that have the best flow, segment their care. In high-volume EDs, they may have areas for low-acuity, medium-acuity, and high-acuity treatment. For low- and medium-acuity patients treated by RN-physician teams, it often becomes a flow-based system instead of a ratio-based system. In other words, the team may only have two patients at a time, but they could have treated four patients in the hour. A flow-based system allows for the treatment of more patients. Organizations that segment by acuity may use a nurse staffing model where they partner with physicians and match their hours of the day and arrival patterns with the workload of those providing the care.
The number one thing to remember is that we all want to give great care to our patients. Physician, nurse, and C-suite leaders should come together to figure out the best staffing for their organization. With all three perspectives at the table, and on the same page about how to optimize staffing and flow, it’s possible to make giving and receiving care better for all.
Karen Murrell, MD, MBA, is Chief of Emergency Medicine and Assistant Physician in Chief for Process Improvement and Optimization, Kaiser South Sacramento. She will be faculty for IHI’s Hospital Flow Professional Development program.
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IHI White Paper - Achieving Hospital-wide Patient Flow