Accelerating Change: Can a Collaborative Approach Achieve Breakthroughs in ED Turnaround Times?

If there's a constant in today's healthcare environment, it's change.

Earlier this year, I was working with a group of Vituity partner hospitals to reduce emergency department (ED) turnaround time to discharge to 115 minutes. Several facilities were hovering at 150 to 180 minutes and doubted they could shave away an hour.

When our organization's program director suggested that I gather staff from the various sites to discuss strategy, I hesitated. After all, each ED has its own challenges, goals, desires and culture. I didn't think the problem lent itself to a one-size-fits-all solution.

But then I wondered: could our organizations accelerate change by working together? I thought back to my experience with the Institute for Healthcare Improvement's (IHI's) second Breakthrough Series Collaborative.

In the mid-1990s, IHI pioneered a collaborative model aimed at accelerating improvements in quality of care. The resulting programs (known collectively as the Breakthrough Series) were designed to close gaps between research and practice.

In the IHI's words:

"A Breakthrough Series Collaborative is a short-term (6- to 15-month) learning system that brings together a large number of teams from hospitals or clinics to seek improvement in a focused topic area."

In 1996, I participated in IHI's second collaborative, which focused on reducing adverse drug events (ADEs). Over 15 months, 40 hospitals tested and implemented evidence-based processes. Along the way, we met face-to-face with experts and received support from the collaborative faculty and our fellow participants. In the end, 70 percent of the participating hospitals met their goals for reducing ADEs.

Fast-forward 20 years. With healthcare reform moving us rapidly toward a system that rewards quality over quantity, the need for change has never been greater. Meanwhile, IHI's Breakthrough Series Collaboratives continue to achieve stunning results in areas from cesarean section rates to ED wait times.

The model seemed to be the perfect match for our ED initiative. So with funding from Vituity, our practice management group and key Vituity leadership organized a yearlong collaborative aimed at improving ED turnaround time to discharge.

Eleven Vituity partner hospitals committed to organizing multidisciplinary teams to identify and test evidence-based processes. Over the next year, they will participate in learning sessions that bring team representatives face-to-face with subject matter experts and "application" experts — nurses and providers who have successfully reduced turnaround time in their own EDs.

We just completed our first two-day learning session, which brought together 5–8 participants from each site. Our first day was dedicated to learning about the impact of culture on successful change, how to manage change and "The Marketplace," a series of breakout sessions in which subject matter experts introduced evidence-based strategies shown to reduce turnaround time. Areas covered included:

  • Front-end processes: Rapid Medical Evaluation (RME), nurse-initiated protocols, quick-look nurse in triage, immediate bedding and team intake.
  • Workups: team assessment, point-of-care testing, quick emergency disposition (QED) and other communication strategies, agreed upon workups with hospitalists and use of an internal lobby.
  • Discharge processes: team discharge (a strategy most often implemented by our sites), change-of-shift sign-offs, case management's role and streamlining admission processes.
  • Ancillary strategies: use of scribes, lab and imaging best practices, standardization of procedure carts, patient transport and CT utilization.
  • Culture: staff recognition programs, performance incentives, readiness for change and using data to support change.

Following the breakout sessions, site teams regrouped and shared what they'd learned. Together, they identified improvement strategies that made sense for their sites. Monthly touch base/coaching calls are planned to help keep the sites on the path of successful improvement.

The remainder of the learning session was spent discussing and applying IHI's "Model for Improvement":

  • Aim: What are we trying to accomplish?
  • Measure: How will we know that a change is an improvement?
  • Select and Test Changes: What changes can we make that will result in an improvement?

In April 2014, the entire group will reassemble for a second learning session to share methods and results, troubleshoot issues and learn from and support one another.

So far, feedback on the collaborative has been overwhelmingly positive. Several sites remarked how difficult it is to find time to work together and concentrate on strategy. For them, simply coming together in a supportive environment was powerful. Others reported breakthroughs in relationships and a renewed sense of energy and purpose. Within just two weeks, many sites have completed their first and second tests of change with great success in reducing their turnaround times!

We're at an exploratory stage with the collaborative, but we believe our sites will have a better chance of success under this model. Can they stretch to achieve big changes over the next year? Stay tuned, as I'll be stopping back to report their progress.