How to Get a Handle on ED Overcrowding

Joe Cantlupe, for HealthLeaders Media , May 30, 2013

Success key No. 4: Patient satisfaction
One of the major goals for hospitals working to improve the patient flow is to achieve patient satisfaction. It's no easy task. The ED is often a chaotic place, with disruptions and people suffering from various degrees of illness or injury. Waiting times might prompt patients to leave before being seen because they perceive that the hospital is taking too long.

"We live in the real world," says Zimmer of St. Mary. "Some patients are upset with us." While the Centers for Medicare & Medicaid Services has not released national statistics about how many patients leave hospitals without being seen, an Annals of Emergency Medicine study published in 2011 found a median percentage of 2.6%, based on 9 million ED visits to California hospitals. However, the range varied widely from lower than 1% to 20.3%.

Of the hospitals profiled in this story, rates for patients leaving without being seen ranged from 0%–2%.

Wadas says the organization's hospitals "have rates of 0% to 0.1%, depending on the month; it's actually that low. If you think about it, if that number is high, you are not meeting people's needs and so you are not providing service. That was a big goal of ours to make sure that number was low. That number is partially dependent on the rest of the process. If all your beds are clogged up and people are there for hours and hours, you can't get people in the waiting room into beds, get them seen and taken care of."

Ingalls' rate for patients leaving without being seen is 2%, but was high as 10% a few years ago, says Mikos.

Paul Zielske, director of patient care and emergency and surgical services for Ingalls, attributes the reductions to "the changes that we've put in place, and shows what can happen with an effort: You can decrease those times."

At the same time, he notes, the hospital's ED volume increased from 42,000 to 49,000, but efficiency enabled the hospital to "have better responsiveness."

When patients leave without being seen, they are, in their own way, expressing deep dissatisfaction with a hospital. By decreasing the number of those patients who leave, satisfaction scores can improve, Zimmer of St. Mary says.

At St. Mary, patient satisfaction registered 95th percentile in 2012, after the hospital expanded its ED and made split-flow changes. Zimmer says that was an improvement over several years and that patient satisfaction with the entire hospital is linked to improvements in the ED.

Patients spread the word when there are long wait times. They even compare notes: "How long did it take for a physician to see you?" Zimmer says. "If you have a poorly run ED, it's very difficult to have inpatient satisfaction. From a business perspective, Medicare dollars are at risk based on HCAHPS scores. If you have ED docs that do not do well, you have a direct risk of losing Medicare dollars because of poor outcomes," he explains.

At George Washington University Hospital, 2% of nearly 38,000 people were reported to have left without being seen. Several years ago, that rate was at least 5%, says Shesser, chairman of GWU Hospital's ED.

"Over the years, we've managed to decrease our 'left without being seen' rate and improve throughput by making little changes and measuring the effect of those changes," Shesser says. "We are certainly paying closer attention to that in the new world of pay-for-value."

At Avita Health System's small Bucyrus and Galion community hospitals, both had to deal with high rates of patients leaving without being seen, at 3% several years ago. "We focused our interdepartmental groups on reducing time lags," says Daniels. As a result, the health system has reduced the 'left without being seen' rate to 0.41% at Bucyrus and to 0.18% at Galion as of January 2013.

"The biggest problem that remains to be overcome is always maintaining the success that you already have," Daniels says. "The more successful we become in our community and as word spreads, we will be the ED of choice. As our volume grows, it will be important that we do not slip and that we continue to meet customer expectations for service."

Reprint HLR0513-7

This article appears in the May issue of HealthLeaders magazine.

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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