Clinical Operations Overview

The Emergency Department (ED) of Northwestern University and Northwestern Memorial Hospital (NMH) has been a rapidly evolving clinical operation since the arrival of the current departmental chair in 2000. In ED projected 83,000 patients in 2008, compared to the 80,000 patient visits in 2007.  Patient visits have increased 5% annually for the past 5 consecutive years. Despite the increase in patient volume, the ED has been able to achieve substantial improvements in the technical quality and safety of the care it delivers, as well as patient satisfaction.

Clinical Operations Team

Martin Lucenti, MD  Vice Chair, Clinical Operations	Michael Schmidt, MD Director, Operations	Rahul Khare, MD Assistant Director, Operations	Matthew Kippenhan, MD Assistant Director, Operations

Highlights

In the last two years, the following initiatives were implemented in the ED in order to increase the global throughput capacity of the department, the quality of the individual patient care provided, and the satisfaction of the patients:

• Bypassing the waiting room in order to prevent queue propagation and shorten overall waiting times.
• Redesigning  the care teams in the main room to increase productivity.
• Transforming urgent care into a rapid cycle unit for patients with high likelihood of being discharged.
• Maximizing the use of capacity resources. Specifically, enabling the observation unit to provide emergency treatment, inpatient care depending upon patient needs.
• Establishing care protocols for high acuity patients to improve measurable quality (MI, pneumonia, sepsis, trauma, and stroke).

The results of these efforts included:

• 5% increase in the number of patients served
• 35% decrease in the time to patient care
• 25% increase in the clinical productivity of the ED attending physicians
• New records established for nearly every quality metric
• Patient satisfaction hit new highs in 2007
• The ED continued to build on its prior success with IT systems and developed a rich operational dashboard enabling real-time monitoring of operational performance.

All of these breakthroughs provide the foundation for what will be the next phase of advancement in the department re-design of operational management. Initiatives in productivity measurement, faculty incentives, flexible staffing, and real-time management models are currently being developed to make the Northwestern Emergency Department (ED) clinical operation the standard by which all academic emergency medicine departments are measured.

Strategic Goals

The Emergency Department has made a very concerted effort to synchronize its strategic goals with the strategic thinking of Northwestern Memorial Hospital.  To that end, the Emergency Department has focused its efforts to:

• Deliver the most effective care based on clinical evidence
• Deliver care that is safe and error-free
• Coordinate care to meet the unique needs of patients            
• Deliver timely and convenient care
• Provide the best physical environment in which patients receive care
• Ensure patient understanding and comfort

Each of our strategic goals outlined above also have associated quality improvement goals.  The end result of these goals is specifically to improve clinical outcomes and processes with a focus on patient safety/reducing medical errors, enhanced pain management, infection control, and population-specific outcomes, with special attention to national quality standards, benchmarks, best practices, and variance reduction. Additionally, we strive to improve patient satisfaction to targeted levels as measured by surveys.

Tactical Efforts 

Continued innovation and effective change management is required to achieve our strategic goals. The ED of NMH continues to grow rapidly. The operational tempo is magnified by the fact that the ED remains a 365-day-a-year, 24/7 operation; there is never a down time. The success of the ED in delivering excellent care with record-breaking patient satisfaction is a testament to the dedication of the caregivers.

Intake, Triage and Decreasing Waiting Time

One of the first innovations focuses on triage - where patients are categorized by urgency of need upon arrival. NMH helped develop and validate the widely-used triage system known at the Emergency Severity Index (ESI) triage system. This system provides the tools to more accurately predict the resource needs of our patients, further ensuring that patients receive appropriate and efficient care.

By definition, triage determines which patients wait. We are attempting to shift this paradigm by asking why patients should wait at all when we can roughly predict arrival times and ensure sufficient staffing to meet demand. Although physical capacity constraints are a major limiting factor, each day we are able to close our waiting room for several hours and provide direct access to treatment areas.

Our goal is to ensure continued timeliness of care. This requires innovative delivery systems that meet the demands of both predictable and unpredictable patient arrivals and high patient acuity. Ultimately, it is this patient-focused philosophy that drives our team to provide more compassionate, efficient, and effective care.

Toward a Scientific Foundation of Management

By analyzing patient demand, time of arrival, length of stay, turnaround times, and capacity, we can better understand the ED system and identify ways to improve efficiency. We have applied Six-Sigma methodology based on scientifically-informed industrial engineering practices to strategically improve patient care and departmental processes. We are continually achieving ongoing reductions in the time patients wait to receive care and lengths of stay in the ED. These achievements are directly responsible for the ED's improved patient satisfaction and quality of care.

Ultimately, the patient experience is the true benchmark. Restructuring patient flow through the department has changed the culture of our workforce. A 35% reduction in time to care and new records in patient satisfaction (despite an 8% increase in volume and a 30% increase in holding time per patient waiting for an in-patient bed) reflects a commitment by the entire ED team to ensure an exceptional experience by the patient. We will continue to measure and monitor our success and learn from our ongoing efforts so we may continually improve our service to patients and the community.

Teamwork

Obviously, the NMH ED does not work in isolation, but as an integral partner within the larger hospital system. In a sense, it functions as a barometer of the hospital, yet, only by working effectively with laboratory, radiology, consultants, specialists, and ancillary staff has success been possible. We continue to work within the system to streamline and improve care.

Emergency care is always delivered as team. While the new demands of health care delivery show inter-relationships at all levels, in the ED, a full team is always present. High-performance teams comprised of physicians, nurses, technicians, administrative assistants, and registration personnel work in a common physical area in an integrated fashion, thus promoting efficient communication and facilitating teamwork. High levels of team-based performance do not come easily but require training, commitment, and continued emphasis by leadership.

Many of these process, quality, and service innovations are made possible through the generosity of individual donors, alumni, and philanthropic organizations, including the Davee Foundation, Miss Judith Blazer, and other valued donors and friends.

Philanthropy has been a key element in attracting some of the nation's most talented academic emergency physicians to teach our students and care for our patients. In turn, nurse, staffing, resident training quality, and leadership development have flourished.