How to help manage rapid growth in the emergency department

Exploring operational excellence at NYC Health + Hospitals/Queens

Health systems need to be flexible and respond quickly to the various challenges in health system operations, especially the emergency department. Health systems also need to adopt a system that empowers the front-line staff to make needed improvements quickly.

When viewed as a long-term strategy for change, Continuous Improvement with the Simpler Business System can help lead to true transformation. NYC Health + Hospitals/Queens focused on a major transformation in the Emergency Department (ED) starting in 2015 to improve operational and clinical performance.

Dr. Dave Holson, director of the ED at NYC Health + Hospitals/Queens shared his perspective on the value of continuous improvement in a rapidly expanding ED. Highlights from that conversation have been edited lightly for length and clarity:

WH: Describe your community and some of the challenges your ED was facing.
Dr. Dave Holson: We serve the very diverse community of Queens, with more than 130 languages spoken here. I’ve been here 16 years and the ED had a volume of about 60,000 annual visits when I started. The borough has seen significant closures over the last 15 years, and that has resulted in tremendous growth in terms of the volume that we are seeing. We now see 100,000 patients per year. Our ambulance runs went from fewer than a thousand to now 2,500 per month. We were faced with issues of flow, issues of ED overcrowding, limited space. And just how best can we serve our patients and see them flow through the entire hospital system in a timely manner?

WH: What were some of the benchmarks you started with?
Dr. H: The (Centers for Medicaid & Medicare Services) benchmark at the time we started the journey was time and treatment for patients with pneumonia. The expectation was that these patients would be seen and initially started out on treatment at four hours. And then it was increased to six, but it was that they should receive their antibiotics within six hours…But the paradigm shift was we wanted to be better. We wanted to be the provider of choice for our community, so we started this journey toward excellence.

WH: How valuable was the process of mapping the value stream in the ED?
Dr. H: One of the valuable pieces we enjoyed about the journey is the level of granularity with which we approached the subject. It was looking at the flow of the patient from arrival and all the possible combinations of where they could somehow be processed in the ED. Once the whole team saw the layout of demand, it helped us plan for patient flow differently. Then we worked within the context of ‘What does good look like?’ and breaking it down so that we could see where our gaps were, then doing the necessary tests to change them. We even celebrated the failures because that allowed us to learn from that experience and say, ‘How can we do better the next time?’

Learn about how NYC Health + Hospital/Queens reduced wait times and length of stay

WH: What were keys to your success?
Dr. H: We couldn’t do this without the staff, and they were highly motivated because they were involved from the beginning. And we made sure that we were hearing them. As we had successes, people saw the value of this journey. And so therefore it helped to keep that momentum…The [IBM] team, I really felt that they heard us and were willing to make the necessary adjustments. So it really was a collaboration.
WH: What do you find most gratifying about this entire transformation?
Dr. H: For me it’s the culture change. We created a continuous learning environment, and now the staff is ready for change all the time…It is basically part of our fabric and we’ve been able to continue to make changes, grow and pursue excellence.

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