The document discusses redesigning and expanding a university hospital emergency department to improve patient care and outcomes. The goals of the redesign were to shorten wait times, improve patient privacy and staff ergonomics, and increase the ED's capacity to care for patients. The redesign included adding more patient rooms, reconfiguring spaces for improved workflow, and designing a more healing environment. The expected outcomes were shorter wait times, improved patient and staff satisfaction, better recruitment and retention of staff, and improved patient outcomes. The redesign's effects would be evaluated using run charts and patient/employee satisfaction surveys.

1. Redesign and Expansion of a
University Hospital Emergency
Department
Mandi Woronowicz

2. Purpose
Increase and Enhance ED’s ability to care for
patients
 National Quality Forum (NQF) Measures 14
◦ Time from door to physician
◦ Length of stay
◦ Left without being seen
• Joint Commission: ED is most common place for
sentinel events in hospitals 15
 Extended wait time can increase harm to patients 5
◦ Institute of Medicine (IOM) calls it “National
Epidemic”
◦ Possible acute coronary events
◦ Greater mortality

3. Purpose (cont.)
 Lack of patient privacy
 Mediocre ergonomics for staff
 Hospital not allowed to go on “bypass”
 Fairly high level psych and crime victims
 Patient satisfaction ratings mediocre

4. Expected outcomes
 Shorter patient wait times
◦ Less patient angst and perception of being
ignored12
◦ Improved patient outcomes 8,12,14
• Greater patient privacy and lower noise levels 9,
11,13
• Improved staff ergonomics
◦ All face patient rooms 2
◦ Able to view entire trauma area 2
◦ Improved mood 7 and communication between co-
workers 6

5. Expected Outcomes (cont.)
 Improved Patient Satisfaction 8
 Improved recruitment and retention of staff 4,9
 Improved workflow 9, 12
 Improved psych privacy; rooms with doors 9

6. Measurements for Evaluation
Timestamp Run Chart
1 2 3 4 5 6 7 8 9 10
Time 4 4.5 3 5 4 1 0.75 1 0.5 0.5
Target 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5
0
1
2
3
4
5
6
AverageHours
Post
Pre-Redesign
Time from Hospital Door to ED Room

7. Measurements for Evaluation
 Run Charts
◦ Time from door to physician 14
◦ Length of stay 14
◦ Left without being seen 14
◦ Registration time 12
◦ Triage Assessment time 12
• Patient Satisfaction Surveys
• Employee Satisfaction Surveys 5

8. Procedures Used
 Compiled input of all stakeholders for
requirements and design 4,9, 11
 Conducted Failure Modes and Effects Analysis
(FMEA) 11
 Videotaped and process mapped workflow 7
 Sketches of remodel posted for public and
employees with attached pad for comments
 Construction performed by section for least
amount of disruption
◦ One side of square shaped ER at a time
◦ Then triage and waiting room across hall
◦ Relocation of supply, utility, and linen rooms

9. Procedures used
 Designed healing environment with goal of
patient centered care 9, 11
◦ Permanently stained tile floors replaced with sustainable
wooden floors
 Pleasant environment 9
 Stains easier to remove
◦ Windows in all patient rooms
 Comfortable and healing for patient 9, 11
 Staff performance better with natural light *9
◦ Separate triage area from waiting room; chairs for patients
in triage 9, 10
◦ Increased number of patient rooms 10,12
*43% of staff said very positive effect; 27% said positive

10. Personal Analysis
 ED is a High Reliability Organization (HRO)
 Multidisciplinary triage
◦ Tests ordered with follow up 1, 12
◦ Medications given sooner 1, 12
◦ Earlier diagnosis and admission (if necessary)10,
15
◦ Improved patient flow 15,16
◦ Patients more stable when transferred 6
• Patients no longer lining hallways
• Improved hand washing compliance vs.
sanitizer; patient room sinks next to hallway

11. Personal Analysis
 Centrally located supply room; 8,9 Lean
process implemented to ensure supplies
always in stock 3
 Improved patient care8 and patient outcomes
14
 Improved patient satisfaction 12,13
 Improved staff satisfaction 8,9, 13

12. References
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December). Impact of Rapid Entry and Accelerated Care at
Triage on Reducing Emergency Department Patient Wait
Times, Lengths of Stay, and Rate of Left Without Being
Seen. Annals of Emergency Medicine, 46(6): 491-7.
2. Chaudbury, H., Mahmood, A., & Valente, M. (2009, May
5). The Effect of Environmental Design on Reducing
Nursing Errors and Increasing Efficiency in Acute Care
Settings: A Review and Analysis of the Literature.
Environment and Behavior, 41(6): 755-86.
3. Dickson, E. W., Anguelov, Z., Vetterick, D., Eller, &
Singh, S. (2009, October). Use of Lean in the Emergency
Department: A Case Series of 4 Hospitals. Annals of
Emergency Medicine, 54(4).

13. References
4. Harrison, S. (2004, July 28). Bad hospital design leads
to poor staff performance. Nursing Standard, 18(46): 7.
5. Horwitz, L. I., Green, J., & Bradley, E. H. (2010,
February). US Emergency Department Performance on
Wait Time and Length of Visit. Annals of Emergency
Medicine, 55(2): 133-41.
6.Horwitz, L. I., Meredith, T., Schurr, J. D., Shah, N.R.,
Kuikarni, R. G., & Jenq, G. Y. (2009, June). Dropping
the Baton: A Qualitative Analysis of Failures During the
Transition From the Emergency Department to Inpatient
Care. Annals of Emergency Medicine, 53(6): 701-10.e4.
7. Lees, L. & Ferreday, J. (2003, August 12). The role of a
flow coordinator in an emergency assessment unit.
Nursing times, 99(32): 32.

14. References
8. McCarthy, M. (2004, July-August). Healthy Design.
The Lancet, 364(9432): 405-6.
9. Mroczek, J., Mikitarian, G.m Vieira, E. K., & Rotarius,
T. (2005, July-September). Hospital Design and Staff
Perceptions. The Health Care Manager, 24(3): 233-44.
10.Paul, S. A., Reddy, M. C., & DeFlitch, C. J. (2010,
August-September). A Systematic Review of Simulation
Studies Investigating Emergency Department
Overcrowding. SIMULATION, 86(8-9): 559-71.
11.Reiling, J. (2004, Fall). Facility Design Focused on
Patient Safety. Frontiers of Health Services
Management, 21(1): 41-51.

15. References
12.Spaite, D. W., Barthalomeaux, F., Guisto, J.,
Lindberg, E., Hull, B., Eyherabide, A., Lanyon, S.
…Convoy, C. (2002, February). Rapid Process
Redesign in a University-Based Emergency
Department: Decreasing Waiting Time Intervals and
Improving Patient Satisfaction. Annals of Emergency
Medicine, 39(2): 168-77.
13.Welch, S. J. (2010).Twenty Years of Patient
Satisfaction Research Applied to the Emergency
Department: A Qualitative Review. American Journal
of Medical Quality, 25(1): 64-72.
14.Welch. S. J., Asplin, B. R., Stone-Griffith, S.,
Davidson, S, J., Augustine, J., & Schurr J. Emergency
Department Operational Metrics, Measures and
Definitions: Results of the Second Performance
Measures and Benchmarking Summit. (2011, July).
Annals of Emergency Medicine, 58(1): 33-40.

16. References
15.Welch, S. & Davidson, S. (2010). Exploring New
Intake Models for the Emergency Department. American
Journal of Medical Quality, 25(3): 172-80.
16.Wiler, J. L., Gentle, C., Halfpenny, J.M., Heins, A.,
Mehrotra, A., Mikhail, M. G., & Fite, D. (2010,
February). Optimizing Emergency Department Front-
End Operations. Annals of Emergency Medicine, 55(2).