Applying Management Models Improves Length of Stay Stats by 25 Percent

About three years ago, Cullman Regional Medical Center (CRMC) hit a wall of dissatisfaction with their ER. "We were hearing a lot of complaints from the community about our ER. Our physicians and staff were dissatisfied," says Cheryl Bailey, RN, BSN, MBA and CNO, and VP of Patient Care Services.

The complaints from the community focused on the long lengths of stay, averaging 94 minutes. Two percent of patients left without being seen. "Our wait time beat the national average then," Bailey says. "But our community expected more, so we knew we needed to work harder."

About then, CRMC began setting aside a full day each month to train their 30 to 40 high level directors in strategies to improve effectiveness. The topics changed regularly. Several of those sessions exposed the administrators to two leading management models, Six Sigma and Lean.

"Lean is about eliminating waste, and Six Sigma is about getting down to perfection," Bailey says. The management techniques, originally derived from manufacturing giants Motorola and Toyota, looked improve efficiency without hampering quality. They were wildly successful.

Bailey put them both to use in overhauling the Cullman Regional ER. "We wanted to look at things differently," she says. " We asked where there was wasted time or work we had to redo."

Staff at every level became involved. However, it grew to be obvious that the ER physician group in place at the time was not on board with the transformation effort. So CRMC spent six months hiring a new group, Pegasus, to staff their ER. "And that was on a fast track," says Bailey, who admits she's had numerous "high blood pressure" moments in this multi-year overhaul.

Bailey and her team asked staff members at every level, in and outside the ER, plus experts, patients and community agencies what they saw happening in the ER and what needed improvement. "They could all see different steps that led to increased length of stay, like the time it takes to get a lab result or to get to and from diagnostics," Bailey says. "When all the staff is looking at it from different viewpoints and agendas and needs, they can really give you great ideas of ways to improve."

Using the Lean model, CRMC strove to uncover the root cause of every issue, rather than patching the consequences along the way. "It's a process of asking why over and over again for that issue, as you drill down to the cause until no more why's can be uncovered," Bailey says.

For the issue of length of stay, the staff began asking questions like, 'why were patients sitting in the waiting room when beds were available?' The answer: because they hadn't registered yet. "When you get to the cause, you can look at processes and figure out how to be lean," Bailey says.

So more "why's" followed to determine the problem within the registration process. Why did the person need to be in the lobby to fill out their registration? Why did a complete registration need to be done before triage began? Why couldn't registration be mobile or inserted at some point when the patient had to wait for some other process, such as results or a physician to be free?

The answers meant changes. Now registration comes to the patient. The in-depth questions get asked bedside, so no beds stay empty if there's a chair occupied in the lobby.

"We looked for staff to recognize that the patient in the lobby is still their patient even before triage. So take them right back to the open bed. Now you've eliminated a couple of steps from the old process, and that's a patient satisfier," Bailey says.

The most surprising root cause to Bailey was staff members saying, 'that's the way we've always done it.' "We had to remember the only reason we're here is because of the patients. Whatever it takes, whatever needs to change, we need to do that," she says.

But the new viewpoint toward transformation unsettled some employees. "The whole culture of the ER had to adjust for all these changes to be effective," says Bailey, stressing how the buy-in from staff was what made it possible.

Not surprisingly, a few staff chose to leave instead, "and that's not always bad," Bailey says. "With so many drastic changes in such a short time frame, you expect some resistance."

The CRMC ER volume has risen by more than 10,000 patients over the 34,000 seen this time last year. Yet the length of stay for emergent care patients has dropped by 25 percent, from 94 minutes to 70 minutes. "You get the right people at the table to look at an issue and just throw everything at the wall, and something will stick that's worthwhile," Bailey says.

But she says they're still not done. "I'm not sure we're ever going to be completed, because there's always new issues that pop up. You always have to look at ways to improve."

Next Month
ERs Efficiency, Part Two: Express Care and the dramatic change in use of space.