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How one Houston emergency department fixed their throughput and improved overall satisfaction by 20%

Toward the end of 2017, leaders at the emergency department of Houston Methodist Willowbrook Hospital faced some all-too familiar challenges. They knew something had to change.

Patients complained about long wait times, and a general sense of confusion, when they came to Willowbrook for care. These complaints manifested themselves in Willowbrook’s overall HCAHPS satisfaction scores: just 55.6% of patients reported feeling satisfied with their encounters in the ED.

“We knew we had to do something, and fast,” said Keith Barber, Willowbrook’s CEO.

This is the story of how the staff at Willowbrook’s ED came together to effect a remarkable transformation, not only making patients happier, but improving employee and provider satisfaction as well.

Service triage

First, Barber knew he needed to uncover the roots of Willowbrook’s issues. Along with Willowbrook’s chief nursing officer and assistant chief nursing officer, he convened three Town Hall–style meetings with the entire ED staff, in order to get their perspective on the department’s troubles.

The three officers learned that disharmony reigned in the ED. Neil Gandhi, MD, one of the doctors working there at the time, called attention to communication problems. Doctors and nurses, he pointed out, weren’t speaking enough with each other, and they complained about their mismatched priorities.

Meanwhile, a disorganized admissions process moved patients erratically through the system. Inpatients and outpatients were commingled, leading to throughput logjams—which was why patients were having to wait so long for care.

In addition, the ED was going through a drastic shift of leadership, as both a nurse manager and the ED’s director had left their roles.

“It was pretty chaotic,” Barber said.

By the end of the third meeting, Barber was convinced that the ED needed some drastic intervention. He convened with the ED’s leadership to propose some changes.

Designing the intervention

The result was an intense four-day incubation of ideas with ED staff, led by Heather Cofer, the ED’s new nurse manager; Garry Thompson, the hospital’s new director of emergency services; Myles McClelland, MD, the ED’s medical director; and Andres Bayona, MD, another of the ED’s physician-leaders.

Each of them felt the import of their discussion. And they were feeling ambitious; as Cofer put it, “We wanted to create Disneyland. The question was: how do we get there?”

They took a three-pronged approach:

  1. Bring clinicians together

Resolving inter-staff tension took priority. First, the team removed some of the physical barriers that came between clinicians at Willowbrook, by having nurses and physicians start to work from the same workstation.

“Putting them in the same workspace really brought them together,” Dr. McClelland said. “It helped them have more conversations and communicate face-to-face, so that they were rowing the boat in the same direction.”

  1. Improve patient circulation

Next, they tackled throughput problems.

“Our motto became, ‘Keep ambulatory patients ambulatory!’” Cofer said. To that end, the team created a Results Pending Area, where patients could go to await lab results after being examined.

The comfortable space had 12 lounge chairs (with IV poles attached) and big-screen TVs scattered throughout. Patients loved it.

Even better, giving patients a place to go helped move them more quickly out of their exam rooms. With the freed-up beds, Willowbrook’s staff members were able to see higher volumes of patients, and get to them much faster than before.

  1. Talk to patients

Finally, Thompson spearheaded an approach that would improve how patients experienced their time in the hospital.

“We wanted every staff member to narrate patient care,” he explained. “We wanted everyone to feel that communicating about care was a part of the care process, just like anything else we do.”

Nurses, technicians, and physicians were expected to verbally walk patients through each step of their care. Training staff to narrate care consistently was no small feat, but Willowbrook’s leadership knew it was important.

“We, as clinicians, know what’s going on, but patients don’t have our training or our expertise,” Cofer said. “It’s a responsibility we have, to explain what we’re going to do to them.”

Validated by results

Though none of these interventions worked overnight, it wasn’t long before the team noticed a drastic change in how the ED operated.

The most immediate impact came from a newfound harmony between nurses and physicians. Patients’ reported scores for “Provider/Nurse Consistency” rose dramatically, from just 64.4% positive in October 2017 to 81.4% positive in September 2018.

And where care had been scattered and confusing, patient comments (captured through Real-time feedback) now noted how cohesive the Willowbrook experience felt.

“Great service, got me in and out in a very timely way,” one patient said. “Communication was definitive and timely. Thanks!”

“Was very comfortable with the care and communication with the staff at the emergency center,” said another.

The policy of consistent care narration also made an impression, benefitting both patients and staff. “The more nurses stuck to this, the more anxiety decreased, for the nurses and for the patients, too,” said Cofer. “It helped a lot with staff who are a little more reserved or introverted. Articulating what was going on gave them a way to build rapport.”

All the conversation resulted in improved relationships, across the board. “Scores for nurse and physician communication went up a lot,” Dr. McClelland observed. Positive responses shot up almost 15%, from 61.7% positive in October 2017 to 76.4% positive in September of 2018.

Finally, Willowbrook’s logistical changes also hit their target. Patient admissions moved much more smoothly and the Results Pending Area functioned as intended, cutting wait-times down by an average of almost half an hour (26 minutes) from October 2017 to September 2018.

The combined effect of these initiatives had a significant impact on Willowbrook’s ED satisfaction scores. From October 2017 to September 2018, overall satisfaction went from 55.6% to 77.6%—an incredible jump.

Remembering why

Willowbrook’s team, of course, takes pride in what they’ve achieved. But they also recognize that they can’t rest on their laurels.

Relationships are what made the difference here,” Cofer noted. “And to keep relationships up, it takes work.”

Barber also believes that the work at Willowbrook won’t slow down. “These satisfaction scores are gratifying to see, but we’re not just out here chasing good feedback,” he said. “What matters is that we stay the course, and keep on providing excellent care.”

High satisfaction scores aren’t the goal. They’re a side-effect that comes from keeping patients first among the organization’s priorities, a sentiment Dr. McClelland summed up well.

“When patients come in to our ED, it’s always one of the worst days of their lives,” he said. “So we have to ask ourselves, what are we trying to accomplish here? Who is all this really about? Every day, always—it’s about them.”