Thursday, June 14, 2001

Patients are waiting? There are delays? In my ED? I’m shocked, shocked! - Part 1

But are you? As patient volume climbs and primary care providers and consultants become ever less available, waiting in the ED stretches on forever, or seems to if we listen to our patients’ complaints or review the results of recent satisfaction surveys. You have heard this, haven’t you? Hasn’t your administrator brought you recent results of the hospital’s patient satisfaction survey from the winter just past and wasn’t ED waiting time one of the hospital’s lowest rated measures?

For over one year now I’ve been encouraging you, gentle reader, to measure various facets of what goes on in your ED. Patient time in the ED is only one measure, but one very much on the minds of your patients and your administration. As I described two months ago in the April 2001 column, patients are "demanding excellent, speedy, available convenient health care." Your administration, which is actively competing with nearby hospitals, is looking for the same.

Measuring the patient’s "registered time in the ED," "waiting time" or "throughput interval" is the first step towards addressing it? How are you measuring and reporting this parameter at your hospital? Unfortunately, many of you, with the poor quality tools available can only measure pretty broadly—for example from patient arrival until patient discharge. You may not be able to group patients by disposition in our measurements and most assuredly you don’t measure and report patient time in the ED in percentiles, but more likely only as an average. Reported as an average, this measure is not merely insufficient, but misleading, but is often all that’s available from your systems.

Why should you measure and report your "throughput interval" in percentiles rather than as an average registered patient time in the ED? Because averages assume a uniform "bell-shaped" distribution and we all know that some ED patients spend unusually long periods in the ED, in fact we call them "outliers." Percentile reporting permits the acknowledgement of outliers yet allows for tracking and management of service performance.

For example, most of you can recall when going to the bank meant choosing a teller’s line, getting into it and immediately regretting that you had not chosen a different line. About 15-20 years ago many banks began implementing a single queue for all waiting customers and as a result, we all got to the front of the line faster than if we had chosen a "slow teller" but perhaps not as fast as if we had luckily chosen a "fast teller." What does this observation have to do with measuring ED patients’ "throughput interval?" Well, your bank has a standard for customer waiting time in line and the people who work in that branch know at what point in the queue the standard will be breached. The bank has set a customer service standard for example (this may not be true for your bank) that 85% customers will get to a teller in 10 minutes or less and the branch manager knows at what point on the queue that standard will be breached. Typically, the branch manager or teller supervisor will open another teller window as the waiting line of customers approaches that point.

Ah you say, now I understand, if only the airlines operated that way. Well, they do, they just set their standard much lower, perhaps as low as 70% of customers waiting 20 minutes or less.

Getting and analyzing data in this way is easy with an ED information system, but difficult if the only automation you have is the hospital registration system. Of course, measuring patients’ registered time in the ED does nothing to get at the causes for it.

Another way of getting at the same idea is to look at preset intervals. Some hospitals have learned to report this interval in multi-hour "chunks." Intervals of less than two hours, two-to-four hours, four-to-six hours and over six hours are often used. One can then describe the fraction of the total patient volume (percentage of patients) whose registered time in the ED falls into each of these tracking periods. This is the approach to reporting at the QI Project® for registered patient time in the ED.

If you’ve been reading my column over the past year, you’ll recall that I’ve extolled "base-lining" and discouraged benchmarking. So why do I point you to the QI Project®, a benchmarking site? Mostly so that you can consider adopting the definition they use and also so that you can determine if your hospital is one of the 1500 or so hospitals that report data to this consortium. If so, it will make your measurements, the first step to improvement, easier.

In the examples of the bank and the airline counter I describe different standards. Setting standards is a rather foolish way to operate. It is what your administration does when without consultation with you and consideration of the ED’s capacity to adhere to the standard, your administration advertises, for example, that all patients will be seen by a physician within 30 minutes of arriving at the ED. Here, the standard is that 100% of patients will have a waiting time of 30 minutes or less to see the physician. Is that achievable? Yes, but not unless your ED has the capacity to perform at this level and few do, though many can be improved—over the course of years—to meet or even exceed this level of performance. Knowing where you stand today is the first step and one well worth undertaking for it tells your administration that you intend to actively manage this measure of quality-of-service.

Next month I’ll address what some hospitals have accomplished in reducing the patient "throughput interval." In the meantime, you might determine if your hospital shares data with the QI Project® or belongs to the Advisory Board Company, a research and consulting organization to which about half of the hospitals in the country belong.

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