Quality Improvement paper

Running head: QUALITY IMPROVEMENT PROJECT: EMERGENCY ROOM WAIT TIMES 1
Quality Improvement Project: Emergency Room Wait Times
John DeAngelis, Ellen Huff and Lowell Smith
Northern Arizona University
Health Care Systems
NUR 676
Dr Enid Rossi
October 12, 2014

Abstract
Emergency department (ED) wait times are an important facet of today’s healthcare.
Multiple studies have shown that extended wait times lead to decreased patient safety and
satisfaction. Medicare reimbursement is now tied to both patient satisfaction scores and wait
times. Hospitals are working to find creative ways to deal with the dual challenges of decreasing
the amount of time patients wait in the ED and increasing their sense of satisfaction after a
hospital visit. This paper aims to explore the current state of ED wait times, how it is a problem,
who is involved in the problem of long waiting times, and what can be done to decrease the
amount of time a patient spends waiting for care. It evaluates the current state of ED wait times
compared to ideal wait times and the reasons for any differences. This paper then explores the
use of a Fast Track program to help improve ED wait times and, consequently, patient
satisfaction scores. It lays out a plan of implementation and evaluation of testing a Fast Track
program in the ED. The goal of this paper is to identify if possible a ‘best practice’ approach to
minimizing ED wait times and optimizing the patient’s experience while in the Emergency
Department.
Keywords: Emergency Department, wait times, patient satisfaction, reimbursement

QUALITY IMPROVEMENT PROJECT: EMERGENCY ROOM WAITS 3
Quality Improvement Project: Emergency Room Waits and Customer Satisfaction
“More and more patients-and their primary care providers are taking advantage of the
emergency department’s ability to offer a 24/7, one-stop shop for all their ailments” (Kutscher &
Selvam, 2013, para. 4). With this continuing increase in volume of ER visits across the nation,
Emergency Departments are struggling to find new ways to adapt and serve their rapidly
expanding customer base.
The Charter of This Team is the goal of improving patient service and therefore
satisfaction in regards to each members’ respective hospital Emergency Department, by
eliminating or reducing gaps of time where services are not being rendered, and by minimizing
frustration buildup in waiting customers.
The steering committee consists of NUR 676 Group 1 triad: John Deangelis, Ellen Huff,
and Lowell Smith. Through multiple group discussions, and regular contact on an online WIKI,
this team has agreed to pursue improvement of patient satisfaction in an Emergency Department
setting. Considerable research has been performed on this subject, and this committee will be
determining which of many organizational and stylistic options would be best suited to apply in
this group’s setting. Logistics, budget, policies, and cultural consideration will all be considered.
There will be several preassemblies of this committee for re-evaluation of the process and the
direction of the improvement project.
The Scope of the project will cover several possible alternatives: adjustments in training
to staff; adjustments in manpower quantitatively an/or qualitatively; re-evaluation of operative
ergonomics of the patient ‘flow’ through – and out – of the department. Other considerations
outside of these parameters will be considered as well when ideas are brought forth during
brainstorming, external contributions or ideas discovered during continued research. However,

the possibility of reviewing an in-house survey from employees and/or patients/customers would
be considered. Any proposals for major departmental changes because of this project will require
initial approval up the chain of command as appropriate, and will also require at approval of a
preliminary budget. Major changes could include such projects as: reconstruction of floor plan or
addition of square footage to the facility; addition of more diagnostic equipment to supporting
departments, such as radiology, laboratory, respiratory therapy, etc.
Importance of this project in regards to our customer base is multi-fold in positive
outcomes. Improved customer satisfaction demonstrated through higher survey scores could be
considered a poll reflecting the word-of-mouth reputation of the hospital. Actual-resultant
decreases in ER wait times will decrease several health risks, including those of patients who
decide to leave the ER before being seen by a Physician, which can equal 3% of ER visitors
(Welch & Savitz, 2012). The patients that wait excessively can be at risk, and the patients who
leave without proper exam could represent significant unknown risks as well. The importance of
making some sort of adjustments of patient ‘down time’ becomes quickly self-evident. This
committee hopes to fulfill a need for better patient perception of care, and better actual delivery
of care. The differences and similarities between these two equally important prospects are
foundational for a successful community hospital’s relationship with its respective community.
This steering committee has considerable hospital-direct experience counted in decades.
All three have served and worked in Emergency Departments at some time during their careers,
with two of the three presently actually assigned to ERs respectively, and the third being an
Intensive Care Unit Nurse. The background, qualifications, experience and motivation of this
steering committee should benefit this Quality Improvement Project by understanding patient

and family member needs and by being able to effectively communicate actions taken to improve
outcomes in each respective individual’s situation.
The considerable progressive movement regarding improvements with ER wait times and
other methods of improving patient satisfaction is the primary challenge. This steering
committee hopes to sift through the copious number of articles and studies to reduce this number
by factors previously mentioned. Once this collection of options has been initially screened, the
next brainstorming session will take place to reduce improvement options to between 3 and 6
possibilities. These ‘finalists’ will then go through a second stage screening process with the
committee. This process will include a check-off list, which is still presently in development.
The check-off list in question will have considerations of program application culpability, such
as budget, logistics and manpower feasibility. The committee will also distribute these finalist
studies and methods of improvement to front-line employees, supervisors, and community
spokespersons for additional subjective and objective feedback.
After an appropriate time allowing for feedback, the steering community will determine a
final decision. Once the specific program has been selected, this committee will write up an
implementation plan: the plan will be reviewed, revised and set for beta-test in a respective
department. If policies need to be designed, the committee will either write these in conference
with, or delegate their construction to the department supervisor whose staff will be
implementing the improvement plan. Staff nurses, the ER Nursing Supervisor, the committee,
and the Director of Nursing will review these draft policies for feedback and possible revisions.
Lastly, with room for change in direction, tools will be designed for evaluation of the
quantitative and qualitative indicators for improvement – either by this committee, or through

appropriate delegation. These tools will provide feedback on the effectiveness of the change
along with the quality of its implementation.
Who cares and what do they care about?
According to Lewis Goldfrank, director of emergency medicine at New York University-
Bellevue Hospital Center, “If it’s an emergency, minutes count” (Sadick, 2014, para. 4). It can be
argued that this applies to customer service as well as life-saving measures. Today’s society is
one of instant gratification (Stempniak, 2013, p.31) and long gone are the days where people
would accept hours’ long waits in the Emergency Department. Additionally, hospital
reimbursement has become tied to patient satisfaction, causing an unprecedented focus on
customer satisfaction in healthcare. Hospital administrators are working to address long wait
times throughout the hospital in an effort to address this “growing consumer mindedness”
(Stempniak, 2013, p. 31). “Patients are comparing service they receive at hospitals to their
experience at a restaurant or hotel,” states Stempniak (2013), “and leaders should be looking to
those service industries for inspiration” (p. 31). So who are the customers of an emergency
department? Patients and family members, physicians, hospital administration, and healthcare
regulating bodies are all considered to be ED customers.
Patients
According to Elmqvist, Fridlund, and Ekebergh (2011), the two most important factors
influencing patient satisfaction in an ED visit are waiting times and information (p. 2610). One
of the greatest points of confusion regarding wait times is the misunderstanding of emergency
triage procedures (Wilkin, Cohen, & Tannebaum, 2012, p. 164). Patients expect to be seen in
their order of arrival and are frustrated, even angry, when others with a more acute illness are
seen before them. Papa et al. (2008) suggest that “An explanation of what they can expect with

regard to care seems to be just as important, if not more so, to patients than information on actual
conditions and can help to alleviate anxiety” (p. 348).
Elmqvist et al. (2011) also point out that there is “a close connection between patient
satisfaction and vulnerability” (p. 2609). Once in the ED, patients place their trust in staff
members, depending on them to provide appropriate care in a timely manner. This is best
summed up by the statement by Elmqvist et al. (2011): “In exchange for a medical examination,
the patient pawns his/her bodily control and time control” (p. 2611). ED staff must constantly
work to minimize this vulnerability by providing information and reassurance at every step
through the visit. When this sharing of information and support does not occur, patients describe
their ED encounter “as being non-caring, where physical needs are more important than the
alleviation of suffering and than a deeper understanding of patients needs” (Elmqvist et al., 2011,
p. 2610). Elmqvist et al. (2011) encourage a change in ED organization and mentality, “where
the subjective lived body with its existential needs and feelings has the same priority in
emergency care as that of the biological body and the physiological threat to life” (p. 2615).
Another contributing factor to long wait times is confusion about emergencies vs. non-
emergencies. Even with clear definitions, patients are sometimes confused about the acuity of
their injury/illness (Wilkin et al., 2012). This leads them to assume everything is an emergency.
Wilkins et al., (2012), state that “educational campaigns should concentrate more on how to
evaluate symptoms and determine when different health problems are potentially life threatening
rather than on… emergency vs. non-emergency” (p. 163). This would help patients to identify if
they needed to go to a community clinic before choosing the ED.
Some patients choose the ‘one-stop-shopping’ of an ED over a community health clinic
that may not have the services the patient is in need of or “does not offer the best health care”

(Wilkins et al., 2012, p. 163, 164). Wilkins et al. (2012) found that many patients experience
poor customer service at community clinic. This perception of substandard service implies that
“one reason people choose EDs for non-emergencies is that they feel more comfortable waiting
for health care in the ED than a clinic where they feel unwelcomed by the staff”. Although
highly subjective, the confusion, convenience, or personal preference of going to the ED over a
community clinic contributes to the long wait times in the emergency department.
Family Members
Family members of patients in the ED place a high value on communication and
exchange of information (Meek & Torsello, 2006; Papa et al., 2008). “Going to an emergency
department is often an intimidating and confusing experience for patients and families because
they fear the unexpected” (Papa et al., 2008, p. 348). Elmqvist et al. (2011) point out “being as
the encounters with the ED staff are fragmented, the caring tasks are often left to the next of
kin…[who end up] playing an important role in providing emotional support for patients during
the ED visit” (p. 2614). Family members are more patient and willing to wait when they feel
informed and engaged in participating in the plan of care.
Emergency Department Staff
By improving ED wait times and increasing patient satisfaction, the morale of ED staff is
improved. “Crowded ED conditions result in increased ambulance offload times, increased time
to clinician review, prolonged patient wait times, reduced patient satisfaction, increased patient
complaints, decreased staff satisfaction and decreased physician productivity” (Shetty, Gunja,
Byth, & Vukasovic, 2012, p. 375).
Emergency department staff members are facing increased pressure from patients, their
families, and hospital administration and the greater healthcare community to speed up their

care, eliminate long waiting periods and provide best-in-practice care. For example, in the United
Kingdom (U.K.) until 2011, the main performance measures for EDs were time-based (Alonso,
2013). They had a four hour door to discharge time target. This meant that staff members faced
conflict between the need to provide quality care and the requirement to meet time constraints
(Alonso, 2013).
Despite these pressures, the art of nursing and speed of care do not have to be mutually
exclusive. In discussing the future of nursing and technological changes, Huston (2013) states,
“Nurses need to make sure that the human element is not lost in the race to expand technology.
The human connection is the art of nursing and nurses need to be actively involved in
determining how best to use technology to supplement, not eliminate, human resources”.
Patients that receive personalized, ‘human’ care from staff members tend to “perceive the care
they receive as being of higher quality than is perceived by less engaged patients” (American
Sentinel University, November 26, 2013, para. 3).
Finally, the ED nurse’s role as a patient advocate can increase patient satisfaction.
“Advocacy by definition is tailored to the individual patient – including his or her cultural
beliefs, fears, and past experiences. Advocacy also means, by definition, inviting patient input
and participation” (American Sentinel University, November 26, 2013, para. 7). Elmqvist et al.
(2011) state: “Increasing the nurses role as the patients’ advocate during the waiting between
[triage] and the encounter with the physician can give the patient a feeling of being respected”
(p. 2615).
Physicians
In the past, providers have been “vague about priority levels and expected wait times”
(Elmqvist et al., 2011, p. 2612). The lack of sophisticated technology, and traditional doctor-

patient roles both contributed to this ambiguity. With ongoing changes to technology, wait times
for things like lab results and diagnostic readings are markedly decreased. With the advent of the
Internet, Wi-Fi, and smartphones, people are no longer willing to wait for information. They
expect that their doctors will provide results as quickly as possible without a prolonged wait.
At the same time, healthcare is moving from a physician-focused model to a consumer-
based model. Doctors are no longer accorded respect and resources without question. Rob Klein
captures that change: “Physicians have to learn that my time is just as valuable as theirs. In days
past, consumers may have been willing to sit in a waiting room for 22 minutes to see a trusted
doctor, but now they’re walking out” (as cited in Stempniak, 2013, p. 32). Health care is moving
towards patient-centered, physician-guided care, where a team of medical and nursing personnel
works to meet the needs of each individual patient (American College of Physicians, 2006,
January 30).
Because of the pressure on physicians to ‘treat and street’ patients in a timely manner,
there is a concern that by reducing wait times, patient care and safety will be compromised. “It is
not clear that the quality of care received by patients actually improves, and it may even worsen”
(Four hour ED rule backfire, 2012, p. 38). The American College of Emergency Physicians
(2012) recognized this possible problem:
Others have noted the potential for providers to deliver lower quality or cursory
assessments in an attempt to shorten the wait time or meet a certain maximum wait time
guarantee, leading to a negative impact on patient care…Processes created to meet
maximum ambitious wait time guarantees may also necessitate more interruptions in
provider workflow and handoffs between providers, introducing additional patient safety
hazards (p. 3).

There is a balancing act between keeping wait times short and providing high quality,
comprehensive patient care. Physicians must join with the rest of the ED staff to actively move
patients through the points of care while keeping them informed of their progress.
“By moving patients quickly to patient care areas for evaluation, patients perceive that
the wait time is acceptable,” Welch and Savitz (2012) state, and “timeliness of care is among
the strongest correlates with patient satisfaction. The time it takes to see a physician (door-to-
physician time) has the best correlation of all” (p. 149). In essence, patients are more willing to
wait if they feel that they are making progress towards seeing the physician and finding out what
is wrong. By providing information to the patient regarding what diagnostics will be ordered and
anticipated wait times, the physician fosters a “sense of safety [and] a secure foundation…in the
encounter” (Elmqvist et al., 2011, p. 2613). A streamlined, efficient process in the ED can
improve patient outcomes and satisfaction. This in turn can increase physician job satisfaction by
decreasing negative feedback received from patients and administration.
Hospital Administration
With reimbursement measures focusing more and more on customer satisfaction and wait
times, hospitals must actively work at improving both. “Hospital executives who ignore wait
times can expect a dramatic reduction in reimbursement” (Stempniak, 2013, p. 31). Due to the
increased difficulty in obtaining reimbursement for services, hospital administrators are
challenged to keep costs to a minimum and increase patient encounters.
Emergency departments are usually a significant contributor to hospital revenue.
According to the New England Healthcare Institute (2010), “that 34 percent of total hospital
gross revenue for inpatient services came from patients admitted through the Emergency
Department. The ED also generates revenue for the hospital through ancillary testing” (p.5). An

increase in patient volume due to decreased wait times can positively impact revenue. Positive
patient experiences in the Emergency Department may also influence a patient’s decision to
return to the hospital for outpatient/elective services.
There are many different groups, or customers, in an Emergency Department. All have a
vested interest in decreasing wait times and length of stay. The next step is to explore what is
currently being done in the Emergency Department and how effective it is.
What are we doing well now and how well are we doing it?
In order to identify what we are currently doing well in the Emergency Department (ED)
we must first identify several factors. This Charter has already identified the key focus groups
within this text which include patients, family members, physicians, hospital administrators and
health care regulatory bodies (Stempniak, 2013). In addition, quality improvement measures
must be identified to include cost of the measures already initiated, which would include
implementation costs of the measure, re-evaluation costs, costs of delays, and revision costs
(Tague, 2005). We will begin this process by identifying key players via a top down flow chart,
and another identifying the overall quality of improvements. Finally we will display a
deployment flowchart that identifies who is involved within the process improvement measures
and how they are affected by each step within the process (Tague, 2005).

Figure 1. Key Players (Stempniak, 2013).
One measure that has been effective in decreasing wait times in the ED and increasing
patient satisfaction scores is the emergence and implementation of Fast Track systems (Amirault,
2012). With excessive overcrowding in the ED comes excessive wait times. Consequently,
excessive wait times increase the likelihood of patient deaths within the hospital by
approximately 5% (Amirault, 2012). Amirault states, “ED admissions have increased by 11%
between the years 2001 to 2006 while the building of ED facilities has increased only 4%”.
(Amirault, 2012, p. 1). While some measures to improve process include patient education; in an
Customers involvedin
quality ofcaredelivery in
the Emergency
Department
Patients
Family Members ofthe
Patient
Hospital Senior
Admistrators
Health CareRegulatory
Bodies
State Board ofNursing CMS
Primary & Seconday
Providers
Physician& Surgeons
PhysicianAssistants &
Nurse Practiotners

effort to help potential ED patients identify what is and what is not an emergency situation, these
type of measures can take significant time to teach and need to be continually reinforced within
the community. Fast Track programs can assist with reduction in ED wait times almost
immediately (Amirault, 2012). Fast track programs are aimed at providing care to individuals
who otherwise do not present with immediate life threatening illnesses or injury. Fast Track is
aimed at providing care to patients that have been triaged and whom fall into the triaged category
of Urgent Care (Cosidine, Kropman, Kelly, & Winter, 2008). Fast Tracks are typically staffed
by Midlevel Practitioners including Nurse Practitioners and Physicians Assistants often under the
supervision of a Licensed Physician. In addition, ED Fast Tracks can care for individuals with
acute non-life threatening illness with improved outcomes as opposed to outcomes associated
with excessive ED wait times which can significantly increase patient mortality (Haley, 2008).
In addition, health care services will soon be extended to another 30 million Americans via the
Affordable Care Act (Amirault, 2012). Therefore, overcrowding conditions are predicted to
become more severe ultimately increasing ED wait times going forward (Amirault, 2012).
Fast Track programs can be very effective at decreasing wait times within the ED since
the focus of midlevel practitioners is to treat injuries and illness including but not limited to
“minor burns, minor broken bones, non-decompensating viral colds or flu’s, insect and animal
bites, and superficial cuts and bruises” (Amirault, 2012, p. 1). This is manifested by the fact that
between 60 and 80 percent of all ED visits are comprised of illnesses and injuries that fall within
the previously mentioned categories (Amirault, 2012). As a result, it is simple to see how fast
track programs can provide an increased effectiveness in expediting the check-in to treatment
processes. Furthermore, the newer streamlined approach assists in decreasing the patients
overall wait and time to discharge.

A study shows that currently approximately 58% of all ED’s have a Fast Track program
in place (Cosidine, Kropman, Kelly, & Winter, 2008). Within this case study 1296 ED
admission were surveyed to assess for criteria that would qualify them for inclusion into the fast
track program. Of the 1296 cases 822 individuals qualified for inclusion into the case study
(Cosidine et al., 2008). The Fast Track study was set up in a pre-existing area within the ED
using currently employed or contracted Physicians and Midlevel staff members as Fast Track
service providers. Additionally, a similar number of ED admits were chosen as case studies
from patients treated in the Emergency room. Admission criteria into the study within both the
Fast Track group and the traditional Emergency Medicine group consisted of cases including but
not limited to “minor burns, minor broken bones, non-decompensating viral colds or flu’s, insect
and animal bites, and superficial cuts and bruises” as previously stated (Amirault, 2012, p. 1).
Study findings were remarkable with a stark degree of contrast regarding the Length of
Stay (LOS) between the two study groups. First the Fast Track study group had a significant
decrease in the median LOS from previously recorded studies. Fast track patients within this
study had a median LOS equaling 132 minutes. By contrast the study group that checked
themselves directly into the ED had a median LOS of 313.51 minutes (Cosidine et al., 2008).
Both categories included patients that did not require admission into the acute care hospital. Yet,
patients participating in the fast track study group had an equal chance of being discharged
within 60 minutes at a rate of 14% which was equal to the study group of traditional ED patients
(Cosidine et al., 2008). In addition, discharge rates were higher for Fast Track patients at the 2
hour mark. This was manifested by a Fast Track patient rate of discharge of 53% versus a 44%
discharge rate achieved by traditional ED patients within the same time frame (Cosidine et al.,
2008). Additionally, there was a significant degree of discrepancy for LOS between the 2 study

groups for patients that were admitted into the hospital. Fast track patients were admitted to the
hospital at a median rate of 116 minutes, whereas traditional ED patients were admitted at a rate
of 309 minutes (Cosidine et al., 2008).
The findings conclude that the Fast Track patients not requiring admission were
discharged at a rate of 181.51 minutes faster than the traditional ED patient’s not requiring
admission. In addition, Fast Track patients were admitted at a significantly faster rate than
traditional ED patients were admitted with a difference of 193 minutes. Although there were no
indications that Fast Track rates to discharge or admission were superior to traditional ED
patients at the 60 minute mark since both groups had a discharge rate of 14% (Cosidine et al.,
2008). Yet, upon further review the Fast Track program did not precipitate any significant
benefits to patients presenting to the ED with life threatening illnesses, since their admission rate
was consistent with the rates of admission within the control group for the same category
(Cosidine et al., 2008).
Therefore, the findings of this study conclude that the Fast Track program, which is
relatively new to the pre-hospital patient triage and assessment setting, would be an effective tool
to improve the quality of care within the emergent care environment since expeditious treatment,
admission and or discharge is provided at a rate that is approximately 50% faster than traditional
ED treatment for approximately 60% to 80% of the total ED patient population. It is safe to say
that the decrease in treatment times is highly likely to improve patient satisfaction scores,
increase productivity, decrease the overall cost of care and ultimately improve the quality of care
delivered going forward. In addition, with only 58% of all ED’s providing Fast Track services it
is possible to see that this service could potentially fill the void for most delayed and or deferred
services secondary to overcrowding. This would be possible if the additional 42% of all ED’s

implemented Fast Track programs within their ED’s. Furthermore, this can be precipitated
without the implementation or expense of building new ED’s since most facilities already have
the space required to launch an effective Fast Track Program.
Figure 2. Emergency Versus Fast Track (Tague, 2005).
The average costs of a build out for a Fast Track program can potentially reach or even
exceed 1.8 million dollars (Shushereba, 2010). Yet, Fast Track Programs have the potential to
decrease LOS for patients that meet criteria for Fast Tracking. This can be an effective way to
decrease productivity costs by decreasing the amount of time needed to either discharge or admit
the patient to the acute care setting by at 50%. “The total number of ED visits increased 10%
from 1,586,179 in 2006 to 1,760,527 in 2012” (Legislative Program Review and Investigations
Committee Connecticut General Assembly, 2013, p. 6). With the implementation of the
Affordable Care Act in 2014 it is projected that an additional 30 million individuals that are
otherwise not entitled to services will be eligible for health care insurance under the tenants of
Emergent
Injury or
Ilness Care
Discharge Rate @ 2h
53%
•IncreasedProductivity
•IncreasedQualityof Care
Acute Care Admissin
rate 116min
•IncreasedPatient
Satisfaction
•IncreasedQualityof Care
Discharge Rate 2h
44%
•5% Increase inMortality
Rates
•DecreasedProductivity
Acute Care
Admission Rate
309min
•DecreasedPatient
Satisfaction Scores
•DecreasedProductivity

this act (Amirault, 2012). With this monumental increase in the number of insured within the
United States (US) there will be an exponential increase in the amount of individuals seeking
emergency care in the future. With the implementation of Fast Track programs within the ED it
is possible to streamline patient care activities allowing care providers to increase the amount of
care delivered by 30% to 40%. At a build out cost of approximately 1.8 million dollars for a Fast
Track program it becomes apparent that this is the single most effective way to save time and
money in an effort to meet the looming demands that will be made on the ED’s in the immediate
future (Cosidine et al., 2008). Costs for building an new ED facility can easily exceed 10 to 20
million dollars which is significantly higher than the cost to improve and build out pre-existing
structures in an effort to create a new Fast Track program within pre-existing walls (Stank,
2014). As stated previously, beneficiaries of a new fast Track program include but are not
limited to senior hospital administrators, physicians, patients, patient families and regulatory
agencies (Stempniak, 2013).

Figure 3. Deployment FlowChart (Tague, 2005).
Patients
Shorter Wait
Times
LOS ≤ 132 min
Increased Patient
SatisfactionScore
5% Decreasein
Mortality
Family
Members
Decreasein
Anxiety
Increased Patient
Family
Satisfaction
Physicians &
Midlevels
Better Outcomes
Inceased
Revenue
Secondary to
Increasein
Patient
Satisfaction
Scores
Decreasein
Liability
Secondary to
Decreasein
Mortalityrate
Senior
Administrators
Increasein
Productivity
Increased
Revenue by
Seeing 30-40%
More Patients
Increased
Revenue by
Inceasng Patient
Satisfaction
Scores &
Reimbursement
Payout
Decreasein
Liability
Secondary to
Decreasein
MOrtality Rates
Regulatory
Agencies
Shorter Surveys
Fewer Patients
Complaints
Decreasein
Operational Costs
Secondary to
Fewer Patient
Complaints
Improved Public
Opinion Ratings
Secondary to
Decreased
Statewide
MortalityRates

Quality Improvement Process
Preferred state of care in the ED
In many cases care delivered within the ED can take as long as 5 to 6 hours in order to be
either discharged or admitted (Cosidine, Kropman, Kelly, & Winter, 2008). Exacerbating issues
include increased patient to physician times in which the patient may not be seen by a physician
for extended periods equal or greater than 1 to as many as 2 hours (Cosidine et al., 2008). These
extended periods of time erode patient, family and care provider relationships, trust and
ultimately decrease the level of patient satisfaction. It is the goal of this Charter to identify
process’s that will lead to a significant increase in patient satisfaction by decreasing door to
physician times to 10 to 20 minutes maximum and implementing process’s that have been
proven via evidence based practice studies that will assist in streamlining patient care and
decreasing LOS within the ED to equal or less than 130 minutes maximum. By achieving these
goals we hope to additionally decrease productivity costs and increase ED revenue by as much as
20 to 30% percent over time. This can be achieved by Fast Tracking the 60 to 80% of patients
that fall into a Triage level of 4-5 (Amirault, 2012).
Gaps between current and preferred state
Access to health care in recent years has become more elusive with the revision of
Medicaid within many States. Medicaid increased requirements for individuals to become
enrolled in in the State of Arizona. This change precipitated the disenrollment of approximately
250,000 individuals that were previously enrolled in the Arizona Health Care Cost Containment
System (AHCCCS) (Pitzl, 2011). Many of the individuals displaced from AHCCCS are afflicted
with chronic illnesses which forced them to participate in the plan in the first place. Because of
this fact this issue has become more of a crisis for the ED’s currently operating in Arizona today.

In addition, because the majority of the individuals that were un-enrolled from AHCCCS are
middle aged and or elderly with many having chronic illnesses, there is an increase in the
likelihood that these individuals will have to seek treatment within the Arizona health care
delivery system for acute on chronic exacerbations.
Now that these individuals do not have insurance that would qualify them to receive
treatment at a clinic or participating Urgent Care facility, they will seek care within the ED’s
currently operating in the State of Arizona (Pitzl, 2011). In addition, patients these patients will
delay care because of their lack of insurance and lack of ability to pay. Yet, when they do present
to the ED they will surely be sicker requiring significantly more expensive treatments and
diagnostic testing. Furthermore, these individuals will not be able to pay since they do not have
AHCCCS insurance and most fall before the poverty line. This creates a scenario where ED’s
and hospitals will not be able to be reimbursed for the services that they provided to this patient
population. Yet, the tax payer will continue to absorb this cost since taxes will not be generated
or paid on the significant amount of uncollectable debt that will accumulate for all ED’s and
acute care health facilities (Pitzl, 2011). In addition, ED length of stay (LOS) will certainly be
impacted negatively by the inevitable increase in ED visits by this patient population, requiring a
much higher level of care (Debt.org, 2014). While addressing issues such and AHCCCS
unenrollment it becomes apparent that multiple process improvement measures must be applied
in an effort to improve the overall quality of care delivered here in Arizona by decreasing LOS
and patient to physician times.
Process improvement measures
ED overcrowding is like many other problems in the sense that there is no single magic
bullet that will solve the problem independently. Many hospitals have significant waiting times

often exceeding 5.5 hours that lead to an average walk out rate of approximately 2.3 to 5 percent
annually (Patel & Venson, 2005). The most prominent reason for patients to go Against Medical
Advice (AMA) in the ED is the extensive length of time it took for them to see the physician
(Wykes, 2013). Patients and families often feel neglected and become disenchanted when
waiting to see the emergency care provider. These feelings of neglect often give rise to feelings
of frustration and helplessness. These feelings of helplessness can precipitate a cascade of
emotions and behaviors including but not limited to developing feelings of mistrust toward care
providers, increased anxiety, hopelessness and even anger. Any of these emotions can progress
to a level where the patient feels that their only choice is to leave AMA. By leaving AMA a
patient may be putting themselves at risk for a progression of their current illness or injury
leading to potential decompensation and even death (Patel & Venson, 2005).
Although the patient may have made the choice to leave AMA on their own accord it is
the responsibility of the care providers to do everything possible to precipitate an expeditious
patient physician interaction and communicate any delays effectively in order to allay any
building feelings of anxiety, helplessness, mistrust, hopelessness and anger (Patel & Venson,
2005). As discussed in previous paragraphs Fast Track programs have significantly impacted
patient to physician wait times by decreasing the average ED LOS by as much as 50% in most
cases (Cosidine, Kropman, Kelly, & Winter, 2008). By giving a patient a number indicating how
quickly their patient needs to been seen, based on the acuity of their illness the care staff are able
to triage patients more effectively (Combs, 2012). Patients presenting with a triage number of 1
indicate an immediate need for definitive treatment in order to be stabilized expeditiously (Slovis
& Jones, 2014). Whereas, patients presenting with a triage number of 5, with a condition such as
a cold or flu virus and is otherwise stable and lacks impairment of any kind, other than

discomfort are considered non-emergent. Those patients presenting with a triage number of 1-3
will be checked into the ED while patients presenting with triage numbers of 4-5 are more
appropriately admitted to the Fast Track program (Combs, 2012).
While Fast Track can be highly effective with decreasing LOS by approximately 50% for
triaged patients with a score of 4 and 5 this method does not effectively decrease the door to
physician time for that same patient. Therefore, this method alone will be much less effective if
implemented as a single process for improvement. Several hospitals have introduced additional
measure for process improvement such as Team Triage. Team Triage assists in significantly
improving patient to physician times. A triage team is often composed of an Emergency Room
Physician, an ED Registered Nurse and a Paramedic (Wykes, 2013). The focus is to allow the
Physician and Nurse to assess the patient within 10 to 20 minutes of arrival into the ED waiting
room (Wykes, 2013). This helps the ED staff to expeditiously identify cases presenting with
triage numbers of 1 and 2 in an effort to bring them back into a bay to initiate definitive
treatment (Slovis & Jones, 2014). Patients presenting with triage numbers of 3 are given
increased priority over patients presenting with triage numbers of 4 and 5 and are brought back
to the ED bay as soon as one becomes available (Slovis & Jones, 2014). Patients presenting with
triage numbers 4 and 5 may be discharged immediately or may be required to return to the
waiting room pending lab results and diagnostics that were drawn or provided while the patient
was in attendance at their initial interview with the Physician and Team Triage (Slovis & Jones,
2014). While the process improvement measure Team Triage is effective at increasing door to
physician times by as much as 50 to 110 minutes it is also effective at assisting in decreasing
LOS within 60 to 80 percent of the ED patient population by quickly identifying patients that

present with a triage score of 4-5. This allows these individuals to be placed on the Fast Track in
a more expeditious manner (Slovis & Jones, 2014).
Further process improvement measures to be taken include patient education regarding
what constitutes an emergent health care issue and what does not. This type of education is often
performed by Team Triage when patients are identified as belonging to category 4 and especially
5 since 5’s do not require immediate emergent care (Wykes, 2013). According to Wykes (2013)
approximately 40% of all ED visitors were ill enough to warrant admission through the ED.
This leads us to the conclusion that at least 60% of all ED visits do not require hospitalization
after triage and assessment in the ED. Therefore, 60 % of the total ED population will directly
benefit from education regarding the identification of illness’s that are emergent in nature and
require a visit to the ED. Education should include alternative resources for assessment and
treatment of sub-acute illness and injuries. This would include clinics and Urgent Care facilities,
which can provide a higher level of care than clinics at a significant savings to the patient and
their insurance provider. Rates of savings can be as much as 66 to 75 % depending of the
diagnostic test and treatment being provided (Debt.org, 2014).
Finally, the implantation of team assignments can additionally decrease LOS while
improving the overall quality of care. Teams consist of one physician, two nurses and 1
technician (Patel & Venson, 2005). The premise is that patient care is delivered in a more
continuous manner that expedites care since more than one individual is responsible for each
patient. This precipitates an expeditious performance of diagnostic measures and treatments
since there are more individuals assessing the chart for new orders and additional hands to
perform tasks a higher rate of completion (Patel & Venson, 2005). Studies show that team
assignments increase overall production by as much as 15% by reducing time to physician from

70 minutes to 60 minutes (Patel & Venson, 2005). The percentage of patients seen by physicians
within the first hour increased significantly by 12% from a rate of 56.3% to 64% (Patel &
Venson, 2005). “The number of patients seen by physicians taking greater than 3 hours
decreased by 33% from a rate of 17.8% to 11.8% (Patel & Venson, 2005), while the rate of
AMA discharges decreased by approximately 30% from 2.3% to 1.6% (Patel & Venson, 2005).
In conclusion patient to physician rates were highly affected by decreasing previous time
frames from 1 to 2 hours to 10 to 20 minutes with the implementation of the process
improvement measure Team Triage (Slovis & Jones, 2014). This indicates a process
improvement of 83% overall which is a significantly higher rate of improvement than this
Charter initially expected to see. While the Team Triage measure had the most significant rate
of improvement Fast Track was not far behind in its effectiveness at decreasing LOS. After the
implantation of Fast Track for triaged patients receiving a score of 4 or 5 LOS decreased from
313.51 minutes to a LOS of 132 minutes for discharged patients (Cosidine et al., 2008). This too
is a significantly higher rate of improvement than this Charter expected at a measured rate of
58%. In addition, patients requiring hospitalization had improved LOS from 309 minutes to 116
minutes (Cosidine et al., 2008). This indicates an LOS improvement rate of 42.5% from
previous process’s.
Additional process improvement measures include Team Assignments which could
potentially decrease LOS another 10 minutes overall (Patel & Venson, 2005). Furthermore, this
process improvement measure can increase the rate of patient to physician contact by 8% (Patel
& Venson, 2005). With the implementation of Education for ED clients regarding what
constitutes admission criteria to the ED it is apparent that these process improvement
interventions could significantly impact LOS and patient to physician time frames in a positive

manner. In addition, with only 58% of all ED’s participating in Fast Track programs this process
improvement measure can significantly improve the prognosis of ED crowding in the immediate
future. This is especially important since 30 million Americans will become insured potentially
requiring ED services going forward.
By implementing Fast Track programs within the other 42% of non-participating
hospitals it is apparent the we will require the building of fewer new ED’s since this measure
will be able to increase the delivery of care within the ED by approximately 30 to 40% going
forward. Additional benefits to this measure will be increased savings since Fast Track Build out
expenses typically cost less at an average of 1.8 million dollars as opposed to a minimum
investment of 10 million dollars required to building a brand new ED (Stank, 2014). Fast Track,
Team Triage, Team Assignments and direct patient education by care providers regarding how to
avoid ED visits and what constitutes criteria for an ED visit are each effective individually. Yet,
when applied together in a single process improvement plan it becomes apparent that the
cumulative effect of all four processes can precipitate a significant level of relief on our already
overcrowded and strained ED system.
Root cause
The consistent purpose for this retrofitting and reengineering of the Emergency
Department flow and efficiency is due to the act of responding to a continuing increase in
Emergency Room visits. More Emergency Departments are being forced to adapt to an increase
of patient volumes, many of whom are at a triage level 4 or 5 and could receive treatment
elsewhere, perhaps even with less wait time. The customer demographic of those who attend the
Emergency Department for service has been changing. “Dwindling compensation and rising ED

closures dictate that meeting this challenge demands greater operational efficiency ” (Hurwitz, et.
Al, 2014, para. 1).
This team’s members each performed their own research through Cline Library,
Medscape, Up-to-Date, and other primarily internet-based peer-reviewed resources. Then we
collaborated through electronic group communication – sometimes on telephone, but mostly
using text messaging, so as to be able to remain in communication even away from computers.
With this team in constant discussion, an agreement and consensus on opinion was formed:
while demographic trends were changing in the form of increased Emergency room visits - low-
acuity and otherwise – the majority of hospitals were too slow or even resistant in paying
attention to these changing trends. This lack of foresight preparatory organization has caused the
vast majority of hospitals and their respective emergency rooms to essentially be caught off-
guard in regards to their increase in patient flow and customer satisfaction operative models.
Had the respective leaderships performed their duties on a more evidence-based research
principle, they would have noticed the changing trends, which have been apparent for many
years. The choice of not acting in preparation, and instead operating in a mode of ‘catch-up’, or
‘crisis management’, has led to the situation hospitals are in now. It is apparent to this team
through our respective and collective professional experience that a good portion of this
logistical crisis could have been easily averted.
One portion of the trend that preceded the logistical crisis is the definite increase in
patients who use the Emergency Department as their primary care, instead of attending an actual
clinic. Customers/patients reported many reasons for this change. One primary change in visit
trends is due to actions in response to the following (Nelson, 2011):

 pain, which is/was desired to be addressed as quickly as possible regardless of
acuity,
 either a worsening of, or a continued (read - unimproved) level of, their condition
of illness, or
 a complaint or issue that affected their activities of daily living.
An example of illness complaint that could fit any or all of the above categories, and yet remain
a probable acuity level of 4 or 5, would be a toothache. Considerable pain is typically involved,
the condition never improves on its own, and often a patient would not be able to chew food
without increasing discomfort. The drawback of an Emergency Room visit for a patient like this
is that virtually no ER has a dentist on their staff, and the patient will be treated for pain
management, and will also be given instructions to continue care with their dentist. Once the
crisis (pain) is averted, some patients neglect to follow-up as instructed, eventually repeating the
cycle. In addition, adult patients relying on AHCCCS for insurance do not receive any coverage
for dental needs. This further limits the patient’s ability to follow up as directed and increases the
likelihood of complications. This same trend can be observed with other illnesses as well, with
similar predictable results.
Patients additionally had issues with their effective involvement in their own health care
system. Sometimes patients use the Emergency Department because they simply don’t have a
Primary Care Physician of their own. Sometimes these patients have fallen into the inappropriate
habit of using the ER instead of their PCP because: 1) an appointment isn’t necessary and they
can just walk in to be examined (even without health insurance); 2) they cannot obtain an
acceptable appointment date/time with their PCP due to overbooking, or; 3) they are

experiencing their illness/chief complaint in a time window when their normal PCP is not open
of available (Carret, Fassa, & Kawachi, 2007).
Another precipitating cause the group discussed was the typical lack of knowledge of
current practices, in this case, Emergency Department patient flow. The group agrees that the
term ‘lack of knowledge’ isn’t fully accurate; the knowledge is out there in great volumes. The
term could represent the choice not to acquire new knowledge. While many new models have
been researched for years, their degrees of improvement have often remained overlooked by
facilities and corporations choosing to remain incumbent in their mode of operation. The old
saying goes: ‘if it ain’t broke, don’t fix it’. But the Emergency Room patient management
systems are, by way of entropy, ‘broke’. So now as each leadership group decides it is time to
review the research, and test out a model that would work best in their own particular situation,
the problems that could have been avoided are now deeply entrenched. Instead of progressively
staying ahead in terms of the evolution of care, they are in a constant state of catch-up.
Once the service unit, for lack of a better choice of terms, decides on a new operative
model, the next step is to begin the indoctrination process of the staff into completely integrating
the system into their everyday function. This act can include the redefinition of many employees’
job descriptions; it can also very likely include a great deal of facility policy re-writing in regards
to the new model and its standards of performance.
Fortunately, one of the elements regarding manpower is one that is quickly fading into
the past. That is the application of the mid-level practitioner. This flexible position fills many
possible needs that are as of yet still in the process of being defined. The good news is that the
stigma that some providers have carried toward mid-levels is fading as the usefulness is
becoming more and more self-evident.

Another element to the implementation of these service upgrades is in the improvements
made to the facility itself, which can mean re-engineering a great deal of infrastructure just to
modify existing floor plans. The consideration of additional square footage takes up even more
effort.
With all of these factors acting as a barrier to what should be a continuum of developing
progress in health care, one can see why it is much easier to turn a blind eye in regards to
keeping up with latest health care developments. Now take into consideration the operating
standard of any Emergency Department – it runs 24 hours a day, 7 days a week, 365 days a year
– it is easy to see why hampering a department with the shifting of so many core paradigms
could be intimidating. Nonetheless, there comes a point where this neglect reaches critical mass,
and the changes must be addressed. In the case of this group’s facility, it came in the form of
progressively growing complaints of worsening wait times, and overall poor grades for customer
service.
The other area in Emergency Room treatment that has been frequently ignored is the
focus on levels of customer satisfaction. Customarily, the emotional needs of the patient have
taken the lowest priority in Emergency Services. Considering the original functionality of
Emergency Services, this makes sense. The Emergency Department staff is on hand and trained
for many life-threatening issues, all which take precedence over the frustration of a family
member sitting out in the waiting room. To put it more cynically, there has been no way to bill
for emotional support. However with a rise in patient options, such as a stand-alone Emergency
Room or Acute Care Clinic, the climate has become a buyer’s market of sorts. With this prod in
competition for the patient dollar, more attention has been focused on addressing the emotional
comfort level of patients and the family members who often attend the visit alongside them.

To reiterate, this group believes the root causes comes in the form of an organization that,
for whatever group of reasons, is resistant to change. What is the root cause of this resistance can
be speculated by many, and perhaps they could all be somewhat right with their speculation:
greed, fear, ignorance, complacency, finance, etc. There’s no end to the motivation or lack
thereof in regards to why organizational structures do not keep up with the times. So this group
chooses to remain thankful that this particular facility has finally chosen to take the leap forward.
Solutions for root cause
Often times circumstances in health care, change without much knowledge as to what is
changing and how changes to the demographics are occurring. This is because changes in
demographics are often insidious within a geographical area (Cygan, 2010). In addition,
responses to change can cost a significant percentage of an emergency department’s annual
budget (Hurwitz et al., 2014). Therefore, administrators can become complacent and apathetic
secondary to the changes that they are facing especially since costs can become excessive when
addressing such changes (Carret, Fassa, & Kawachi, 2007). As a consequence changes in
demographics and attempts to keep up with these changes are driven by monetary incentive or a
lack of incentives to deal with these changes, which can make the emergency department
ineffective over time. The implementation of fast track programs, team triage, team assignments
and education programs; designed to educate patients regarding what is an appropriate
emergency department issue, have significant costs tied to them (Stank, 2014). Therefore,
administrators must have an incentive to invest in programs that will assist with reducing wait
times and against medical advice self-discharges in the emergency department (Hurwitz et al.,
2014).

The Hospital Customer Assessment of Health Care Providers and Systems (HCAHPS)
survey has provided the incentive for health care providers and health care systems to improve
their customer service methods which include reducing wait times within the emergency
department (HCAHPS, 2014). By tying compensation to customer satisfaction the Centers for
Medicare and Medicaid Services (CMS) has effectively reduced the level of apathy by promising
that lower scores will be compensated with lower payouts (HCAHPS, 2014). With the promise
of reduced payouts in an industry that already has difficulties capturing adequate revenue to
offset costs, administrators can only face the facts of adaptation or the demise of their
organization and their future within that organization. In addition, administrators that have failed
once within one health care organization will be sure to have difficulty finding another health
care organization willing to take a gamble on them going forward since they have already failed
their previous organization (Hays, 2008). Organizations must identify the customers that they
serve within their organization. In health care this includes but is not limited to patients,
employees, families, physicians, midlevel’s, other senior administrators and regulatory agencies
(Stempniak, 2013). Therefore, it is important for an organization to identify the issues that are
currently preventing or may prevent good HCAHPS scores in the future.
There are twenty seven questions that are asked after the patient has been discharged
from the facility that they were treated in. Eighteen of these questions are core questions
regarding critical aspects of a patients hospital experience including communication with nurses
and doctors, the responsiveness of hospital staff, the cleanliness and quietness of the hospital
environment, pain management, communication about medicines, discharge information, the
overall rating of hospital, and if they recommend this hospital to others in the future
("HCAHPS," 2014). It is easy to see how most if not all of these eighteen questions can pertain

directly to a patients stay within the emergency department. In addition, first impressions are
often the ones that stick with a customer. This makes the emergency department the primary
department required for creating a good impression for the hospitals clientele (HCAHPS, 2014).
By utilizing a modified fault tree a visual illustration can be made in an effort to identify
the resulting outcomes of poor customer services in the emergency department as opposed to
similar incidences in the inpatient units:
As illustrated in the previous graph patient satisfactions scores are easier to improve once a
patient has been admitted since the physician to patient time has been addressed and issues such
Delay in physicianpatient
interaction
In the emergency
department
Bad first impressionof
facility
Poor patientsatisfactions
scores onHCAHPS
Less likelihood to improve
outlook ofpatientfor
facility
Longer wait times before
treatment
Increasein anxiety and
symptomologysuch as pain
and discomfort
In an in-patientunit
Patienthas already seen a
physicianand has a room
placement
Pain issues havealready
been addressed
Higher patientsatisfactions
scores onHCAHPS
There are morecare
providers including Patient
Care Techs, Dieticians, and
Therapists etc.to assistwith
patientcare

as pain, comfort and privacy have been provided for (Hays, 2008). While attempting to provide
for these shortcomings, administrators concerned with dwindling compensation can take
measures to improve this bleak outlook created over the last twenty years. This poor outlook was
created from a lack of investment in management leadership infrastructure and the practical
infrastructure of the physical facility itself (Hays, 2008).
In an effort to progress beyond the crisis of dwindling compensation as a result of poor
patient satisfactions scores, administrators must invest in creating an effective leadership team
focused on developing a new and more responsive management leadership infrastructure (Hays,
2008). Management Leadership Coaching is effective at creating an atmosphere of lifelong
learning and accountability. Leadership Coaches are managers that work with customers on an
individualized basis and assist them in developing goals and creating a plan to achieve these
goals (Hays, 2008). In this case their customers include but are not limited to nurses, therapists,
technicians, physicians, patient care techs, patients and their families. Their approach is tailored
to meet the needs of each individual customer in an effort to optimize the outcome of the goals
and plans identified. Coaches encourage a process of discovery by listening, observing, and
preparing their plans to fit each individual’s needs (Hays, 2008). One approach is to assist in
improving the quality of under achieving employees and process’s within an organization in an
effort to improve employee retention (Hays, 2008). Often by improving antiquated processes the
Leadership Coach can improve the performance of the underachieving employee (Hays, 2008).
Leadership Coaches can also improve the quality of achievement within an organization
and its employees by instilling a culture of continued and ongoing education and learning (Hays,
2008). The value in continued education and learning will help employees to become more
accepting of the inevitable changes that will continue to metamorphosize the environment in

which they work. Dwindling payouts can and have been a significant incentive for change in an
effort to treat patients and families with the highest regard as customers. Leadership Coaches
achieved this by listening to and observing the patients and their families’ relative the concerns
that they had over the past twenty years prior to the implementation of the HCAHPS scoring
system.
One of the primary concerns was increased wait times in the emergency department
waiting room that often reached an average of three and a half hours prior to the implementation
of process’s that inevitably decreased the overall wait to less than half of the previous time. This
included the implementation of the Fast Track program that attempted to triage lower acuity
patients of triage levels 1 – 3 so that they could receive treatment almost immediately during
their triage assessment (Cosidine et al., 2008). Patients with a triage number of 1 and 2 could
often wait in the emergency waiting room for their diagnostic radiological and lab results in an
effort to free up space for higher acuity patients. Leadership Coaches continued to identify other
issues concerning their patients that included long waits to see a physician face to face. After
listening to staff the concept of team triage was developed. Team triage is designed to promote
physician to patient meetings upon assessment in the triage bay. The team consisting of a patient
care tech, a Registered Nurse and a Physician assess the patient upon admittance into the triage
bay. Labs are sent at this time and the patient is taken directly to radiology if diagnostic imaging
is required. Those with a triage level of 1 and 2 are settled back into the emergency department
waiting room pending results. Those with scores of 3 or higher are fast tracked into an ED bay as
soon as possible (Slovis & Jones, 2014). In addition, Leadership Coaching has been effective at
developing additional team approaches that include Team Assignments. These Assignments
consist of two Registered Nurses, one patient care tech and one physician (Patel & Venson,

2005). This approach was developed in an effort to reduce lags and lapses in care for emergency
department patients prior to admission or discharge (Patel & Venson, 2005). This plan was
developed after listening to patients and families and then consulting health care providers
regarding their ideas on how to improve patient satisfaction in this area.
Plan for a Test of Proposed Solution
This Charter has discussed many barriers and possible solutions to the problem of
increased wait times and lengths of stay in the Emergency Room. Our proposed solution is to
create a Fast Track section of the Emergency Room using existing staff and facilities. Due to the
high cost of creating an area specifically dedicated to Fast Track, we will limit our test to using
what is already at hand and, if successful, we will then work towards creating a dedicated Fast
Track area within the Emergency Room.
The Fast Track area will be staffed by a mid-level provider, an RN, and a patient care
technician (PCT) or paramedic. Operating hours are to be 1000-0000 which are normally the
peak patient presentation times in the ER. The area of the ER to be used will be the
Disposition/Procedure (DP) room, consisting of six reclining chairs and one computer station.
The study will run for two months with weekly assessments of progress using the Plan-Do-
Study-Act cycle to facilitate evaluation (See Figure 4).

Figure 4. Plan-Do-Study-Act Cycle (Tague, 2005).
The goals of this test must be beneficial to the process of ER patient flow and reflect our
efforts to improve patient care and overall satisfaction. The goals of this proposed test are:
1. To decrease door-to-provider times to less than 20 minutes,
2. To decrease door-to-discharge time to less than 130 minutes, and
3. To increase patient satisfaction scores from the current level of 81% to 90%.
Discharge goals were set based on research done by Cosidine et al. (2008) showing improved
patient outcomes and satisfaction. Follow-up calls have been proven to show “significantly
increased patient satisfaction, compliance with medication instructions, and the perception of
health improvement” (Cochran, Blair, Wissinger, & Nuss, 2012). These phone calls can be
performed by clinical staff including nurses and PCTs.
We will be focusing on a specific patient group including those who qualify as an
Emergency Severity Index (ESI) triage score of 4-5 (Agency for Healthcare Research and
Quality (AHRQ), 2012). The ESI is “triage algorithm that provides clinically relevant

stratification of patients into five groups from least to most urgent based on patient acuity and
resource needs” (AHRQ, 2012) with one being patients whose lives are in imminent danger.
Patients with an ESI of 4-5 include “minor burns, minor broken bones, non-decompensating viral
colds or flu’s, insect and animal bites, and superficial cuts and bruises” (Amirault, 2012). We
would add sciatica and dental issues to this group as well.
Figure 5. Ideal Treatment Cycle Time (Tague, 2005).
The implementation of this test would be relatively easy in regards to the physical
facility. The DP room already exists for Fast Track patients but is under-utilized by staff. The ER
staffs for a dedicated DP nurse but that person is usually used to float around the department to
assist other nurses instead of opening the DP room. Prior to implementation, the ER nursing
staff, especially the charge nurses, need education regarding the use of a Fast Track program and
the benefits of using the DP room specifically for Fast Track patients.
The largest foreseeable challenge to implementing this program is dedicating one mid-
level provider solely to the Fast Track program. Currently, our facility uses two physicians and
two PA/NPs to cover the entire ER. Taking one away may cause anxiety and stress among the

ER providers. The ER providers also require some education regarding the benefits of using a
Fast Track program. However, we are confident that as the Fast Track program proves to be
useful and helpful in lowering the number of patients that are seen in the main ER, these
anxieties will be alleviated. Cosidine et al. (2008) caution “Failure to staff fast-track areas with
appropriate medical staff results in the cessation of, or interruptions to, fast-track programmes
[sic] and interruptions occur more frequently when medical staff were expected to work between
fast-track and other ED treatment areas”. Having the support of the ER providers is essential for
this program to succeed.
There are three decision points for the continuity of patient care in the Fast Track
program. First, are they an ESI level 4 or 5? This determines if placement into the Fast Track
section of the ER is appropriate. Second, do any diagnostics need to be ordered? This further
differentiates between an ESI level 4 or 5 and gives the team an idea of how short the patient’s
visit in the ER should be. And third, after receiving the results of the diagnostic tests, is the
patient’s condition stable or are they going to require further resources? If they are going to need
further diagnostics or if their condition is more serious than initially presented, the patient may
be removed from the Fast Track program and placed in the main ER for further care (See figure
6).

Figure 6. Detailed Flowchart ofFast Track Process(Tague, 2005).
Patient arrives
Discharge
Provider/Charge
nurse notified
Diagnosis made
Procedures
completed as
needed
Review discharge
instructions
Triage per protocol
Evaluate results
Diagnostics
performed
Seen by provider
Triage performed
Pt. taken to Fast
Track room
Hand off triage to
Fast Track team
Pt. signs in
Triage notified of
patient
Is pt. ESI of
4-5?
Do tests need
to be ordered?
Is patient
condition stable?
Patient to waiting
room
Place in ER
room
Wait for results

Data points will be collected including door-to-triage, door-to-provider, and door-to-
discharge times and customer satisfaction feedback. Data will be collected using a table as
follows:
Date Pt. visit
number
ESI
level
Door-to-
triage
time
Door-to-
provider
time
Door-to-
discharge
time
Date of
follow
up
Form
completed?
Positive
patient
satisfaction?
Need further
follow up?
10/31/14
(Example)
99999 4 5 17 118 11/2/14 Y Y N
Standardization Plan
At the conclusion of the study, all of the data will be evaluated to determine if the Charter
has met its goals. This will show whether the Fast Track program is an asset to the Emergency
Department and is fiscally and physically worth implementing. Data will be analyzed on a
weekly basis and correlated with data from the same time period in the previous year. Line
graphs will be used to show trends and bar graphs will be used for comparison between years.
Figure 7. Example ofWeekly Average Wait Times Line Graph (Tague, 2005).
0
20
40
60
80
100
120
140
160
1 2 3 4 5 6 7 8 9 10 11 12
Minutes
Average Weekly Wait Times in Fast Track
Average Door to Triage
AverageDoor to Provider
Average Door to Discharge

Figure 8. Example ofAverage Times in October 2013 vs.October 2014 Bar Graph (Tague, 2005).
Customer satisfaction is identified by follow-up phone calls using a paper form called
“Post-Discharge Follow-Up Call” (Figure 9). This paper allows the clinical staff member that is
following up with the patient to write notes and comments so further follow-up may be
undertaken if necessary. It is difficult to find the time to follow-up with patients in a busy
Emergency Room and this will be one of the challenges of the Fast Track program. Our ER
currently delegates this task to nurses and PCTs during breaks in patient care. It is not consistent,
as some days are busier than others and some staff are more diligent in making their follow up
calls than others. This follow up applies to the entire ER, not just Fast Track patients. Because of
these barriers, only a small percentage of patients currently receive any follow up contact from
the ER.
0 5 10 15 20 25
10/1-10/7
10/8-10/14
10/15-10/21
10/22-10/28
Minutes
Dates
Average Weekly Door to Triage Times
Times in 2013
Times in 2014

Figure 9. Post-Discharge Follow-Up Call Form (Summit Healthcare,2012).
Long-term standardization.
Since the plans implemented have had such a positive effect, exceeding the ambitions of
the committee, this model must be studied, researched, and duplicated. Caution must be
implemented regarding the program’s early success. While this initial evaluation indicates a
success, additional surveys are recommended in the areas of ER wait times, customer
satisfaction, and door-to-provider times at the three-month, six-month, and twelve-month mark.

These results will hopefully confirm the consistency of the initial results and thereby verify the
solidity of the new model’s effectiveness.
First, all of the newly minted models must be cemented into Facility policies and
procedures. The individual or parties who designed and implemented each particular facet of the
overall improvement model should accomplish this in each particular case. Each newly written
policy/procedure to be implemented must be ratified as per any other new policies, and then they
should be additionally be ratified by the steering committee for verification of interpretation.
Secondly, the model and its policies should have an educational plan developed to standardize
orientation for existing and new employees for these respective departments. Initial stage of this
implementation will be to develop an in-house team of Leadership Coaches (Hays, 2008), who
will develop, refine, disseminate and evaluate the effectiveness of the education program. Once
developed, the individual training modules should be reviewed by the chain of command as
appropriate and by the steering committee. A critical element of training employees to the new
model should include a preceptor program; utilizing those employees within the department who
are already demonstrating: 1-effective early implementation of the original model in their
respective area of expertise, and 2- having quality teaching and training skills. These preceptors,
having a specified training agenda provided by the Leadership Coaches, will orient new
employees to the facility and its new operational model. This continuous effort will help the
model remain consistent and therefore standardized.
One potentially effective strategy in cementing model types like this would be to
publically celebrate its clear improvements in patient care. The facilities customer feedback
scores, the quantifiable decreases in wait times, etc., should all be not only published for study,
but they should also be advertised regionally and even nationally. Education opportunities should

be offered to other facilities within and without of the hospital’s network: inviting administrators
and department heads to our facility as guests to evaluate the improvements first-hand, so they
can consider how our model may be effective in their own respective facilities.
Along these lines, the facility should definitely celebrate its appreciation for its
employees, and all of the efforts and dedication that were needed to implement the program to
such a level of success. Awards of recognition and appreciation should be given to all involved
employees and their families. This show of appreciation should be very public and transparent
that the improvements could not have been developed, implemented or maintained without the
efforts of the employees. These actions are not only deserved by the staff, but they also help a
more positive ‘buy-in’ by the personnel, which will help with long-term consistency.
Finally, the most important element to the equation, the customer, should be included in
the positive improvements that have taken place in their hospital. The ER waiting room and
exam rooms would benefit from posters and pamphlets that show our customers the
improvements we have made in their interests. There should also be a publicity campaign in
local and regional media covering how this facility has adapted to the new developments of
customer needs while increasing safety and decreasing negative experiences in our facility. Press
conferences and news interviews should help bring our efforts into transparency, which is in the
public’s interest.
Another element that should be considered by this steering committee, administration,
and the Leadership Coaches could be a policy developed for vigilance toward future progressive
ideation. The policy is one of maintaining a professional and open administrative attitude for
other new evidence, research and ideas which could help in the same or other areas of the facility
– the attitude should actually be regulated is the one of complacency. Maintaining a progressive

stance will help assure that this and other facilities will not fall into the trap of complacency and
stagnation in any of the areas where the purpose of the hospital – to care for its population – can
be improved upon. Input from employees and the other consumers of our services should all be
reviewed and considered, especially to the level of comparison of developing research.
Conclusion
For too long have health care administrators been indifferent to the needs of their patients
in an ever evolving demographic. There is a need for administrators to become more competent
in promoting a dynamic environment within the emergency department that addresses the
concerns and issues presented by patients and their families. In addition, administrators must be
competent in providing Leadership Coaching to their customers which includes the staff that
provide care within the emergency department. They must take the concerns of the patients and
families and encourage proactive consultation from the staff within the emergency department in
an effort to continue to develop processes such as team triage, team assignments and fast track
departments (Hays, 2008). With compensation from Medicare and Medicaid tied directly to
HCAHPS scores it is paramount to the survival of the emergency department to ensure that all
patient concerns are addressed and process’s developed for new unforeseen issues on an ongoing
basis. In order to become more effective managers and leaders health care administrators must
have ongoing education and training in coaching in an effort to maintain a more effective
management infrastructure and avoid the apathy that had riddled the previous twenty years of
patient care in the emergency department (Hays, 2008).
Expounding on this, most demographic changes within specific areas are often insidious.
This dynamic implies that many of those representing the newer demographic typically have a
knowledge deficits regarding the flow and function of the health care system within their new

geographical location (Meek & Tosello, 2006). Communication and education are paramount to
the improvement and ongoing process of compliance and change. There is an implied fiduciary
responsibility to the customer from the health care system that mandates their proper education
regarding the care and the flow of care within the system that they received that care in (Carret et
al., 2007). Without the delivery of such education the health care practitioners providing the
patients current care are placing their clients at an increased risk for re-admission by not
presenting the information needed for the client to make ongoing informed decisions about their
recovery. Therefore, those individuals identified by the new demographic within the
practitioners geographical area, are subject to higher continuing cost of care that precipitates a
decreased likelihood of payment to the health care system since it is almost inevitable that they
will continue to seek follow-up care at the same emergency department for their continuing
follow up care. With today’s decreasing budgets and increased costs of care and liability it is
paramount that our leader’s foster an increasing awareness for practitioners to provide proper
education for the new demographic of patients. All education efforts should be designed to
minimize patient readmissions over time (Hays, 2008). Although the implementation of new
processes can be exorbitant to the ER budget, the cost of not providing proper education and
implementing effective processes such as fast track, team triage and team nursing can potentially
threaten the survival of the concept of the ER as a viable treatment option within the health care
continuum going forward (Hurwitz et al., 2014).
Ultimately this charter hopes to prove the efficacy of systems such as Fast Track by
performing a two month study in an effort to identify decreased wait times and improved patient
satisfactions scores (HCAHPS, 2014). Primary goals include decreasing door to provider time to
less than 20 minutes, decreasing door to discharge time to less than 130 minutes, and increasing

patient satisfaction scores to greater than 90%. Effectiveness will be surveyed by providing
follow up phone calls to discharged patients in an effort to further assess for adequate education
leading to an increase in compliance with medication and treatment regimens, increases in the
perception of the patient’s health improvement and improved patient satisfaction scores
(Cosidine et al., 2008). All data will be assessed and analyzed on a weekly basis in an effort to
further prove the efficacy of the processes proposed within this study by giving the practitioner
the opportunity to adapt and improve steps within the process on an ongoing basis. By providing
a dynamic study this charter hopes to mirror the dynamic nature of the ever evolving
demographic within geographical boundaries. This should provide a model for future
researchers that will help them keep pace with their evolving patient demographic within their
own geographical location.

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