Methodist Charlton Medical Center in south Dallas is staffed for 225 beds but its emergency department volume is equal to hospitals two and three times larger, says its president, Jonathan Davis. That's why when the ED is having problems, the rest of the hospital's problems are even bigger.
The process challenges at Charlton's ED were numerous, but they all boiled down to a left-without-being-seen rate of 8-10% when Davis arrived 16 months ago.
Since 1975, when Charlton was established as a "feeder" hospital, says Davis, it's seen more than its share of ED visits. That's a challenge in itself. The ED is a magnet for the uninsured, who know they can get care there even if they can't anywhere else.
"We were effectively turning away 5,000-7,000 people a year," he says. "Everyone who left told 10 more people that you can't get in here."
In the past, hospital leaders perhaps didn't recognize the ED's central role as the single biggest source of admissions for the hospital. At Charlton, 65% of its admissions come from the ED. It's not that ED processes and efficiency were intentionally ignored in the past, but it's hard to get motivation for change when the perception is that of the people who are leaving perhaps half of them aren't going to generate any revenue. In the past several years though, that faulty reasoning has been turned on its head.
"The ER is the driver for operations," says Davis. Even without considering the patient care implications of a LWOBS rate at 10%, he says, "we were doing ourselves harm by not having efficient processes. So when I came in, that was the biggest priority."
It was probably the biggest priority for his predecessors too, but they couldn't get it fixed, despite the fact that prior to the latest re-engineering exercise led by Davis and Charlton leaders themselves, three separate consultants hired to fix the problem failed.
It wasn't because they weren't competent, says Davis, who, of course, wasn't around when they did their work. Rather, it was that no one knows the reasons why an ED isn't working properly better than the people who work there and elsewhere in the hospital.
"We placed so much focus on the ER, but we couldn't fix the problem because it was really an organizational issue," Davis says. "We had to get everyone involved."
He found new leadership for the ED. He formed a committee to recommend process changes that included nurse directors, all the administrative leadership, the case management employees and two key physicians. He sent all members of the administrative staff to work in the ED at various times in order to observe and understand the problems faced by the people working in moving their patient load through the ED efficiently. One lesson learned meant that they added a physician in triage to deal with the 30% of cases in the ED that were non-emergent.
"You've already seen the patient and ruled out the emergency, so treat them and let them go rather than sending them back to the waiting room," he says. "If we send them to the waiting room, that's a failure on our part."
The team also looked at occupancy challenges in its inpatient tower. Some were getting outpatient treatment, but using inpatient beds, he says. "We found a new space to meet those patients' needs and not interfere with occupancy."
By pulling reams of data, they noticed that a number of patients could be directly admitted to the hospital not through the ER but from a physicians' office.
Local physicians had complained about the ER being overcrowded, says Davis, whose team decided to create an express admission unit in daytime for physician offices. Today, the outside physician can call a hospitalist and then send the patient directly to the express admission unit, which unburdens floor nurses and gives patients a bed.
Finally, Davis and his team found a way to reduce the volume of non-emergent patients coming to the ED by opening—just last week—a QuickCare clinic on site that's staffed by a physician, a nurse practitioner, and a nurse, 11 hours a day and 12 hours over the weekend.
And he and his staff did it all without outside help. Not bad for a hospital CEO who 20 years ago was a physiologist in Jonesboro, AR. Davis explains his philosophy on solving problems internally when possible.
"I think we as administrators and operators sometimes fail to spend enough time getting to know the business, so we hire good consultants. But sometimes when they leave no one owns the solution," he says. "If we solve the problem, we all understand the issues and figure it out collectively, we never have to get reoriented. It's a process we all have grown through together."
This year, Charlton is seeing many more patients in the ED, and the all-important LWOBS rate is much decreased, although the true impact won't fully be known until the end of the fiscal year, Davis says. Having spent time as CEO at small hospitals in Arkansas, Kansas, and Texas before coming to Charlton, Davis says the ED is the perception-driver in every community in which he's worked.
"Our lesson here is we're not spending money on a facility when we can't improve the process within it," he says. "Operators today really have to understand the business from a grass roots level. Listen to your staff, your community and support it with data."
Philip Betbeze is the senior leadership editor at HealthLeaders.