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Urgent matters
BMC streamlines emergency care with help from SMG professor
By Tim Stoddard
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Boston Medical Center’s emergency department accepts a third of Boston’s ambulances every day, but has managed to serve more patients faster. Over the past two years, John Chessare (from left), Jonathan Olshaker, Linda Fisher, nurse manager of the BMC emergency department, Eugene Litvak, and Niels Rathlev have been working to improve the department’s efficiency. Photo by Kalman Zabarsky |
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It’s the busiest emergency department in New England, serving some 300 patients a day, many of whom are without insurance and/or unable to speak English. But despite the high volume, Boston Medical Center’s emergency department (ED) has emerged as a model of efficiency for hospitals around the country.
“Emergency department overcrowding is a huge national and regional problem,” says Jonathan Olshaker, a MED professor of emergency medicine and chair of the department. “We have an extremely busy ED, but we’re proud that in the past few years we’ve increased the number of patients we take care of and at the same time decreased their throughput time.” The faster service has shaved 45 minutes off the average length of stay in the ED, Olshaker says, to a little over two hours. By keeping the customers moving, BMC has also reduced its annual “diversion hours,” the number of hours each year when the ED is forced to divert ambulances to other hospitals. “This past year, we decreased diversion hours by about 20 percent,” says Niels Rathlev, a MED associate professor of emergency medicine. “If you look at the city of Boston as a whole, the number of diversion hours went up by 1.5 percent over that same time.”
The push for efficiency at BMC is part of a two-year effort to reduce ED overcrowding. The key to preventing logjams, says John Chessare, senior vice president for medical affairs and chief medical officer at BMC, is to optimize every step in the production cycle. “Hospitals and the health-care system have a lot to learn from engineering and management science,” he says. “At BU it’s neat that we have faculty at other schools outside the School of Medicine that we can call on to improve the management of our hospital.”
With a grant from the Robert Wood Johnson Foundation’s Urgent Matters Program, Chessare and Eugene Litvak, an SMG research professor of operations and technology management, set out in May 2003 to identify the kinks in the system that could hinder patient flow through the ED. They organized a team of ED doctors and nurses to gather data on throughput time for patients, measuring how long it takes to move a patient through each step of treatment.
The ED team also began testing “rapid cycle changes,” small adjustments in procedures to expedite patient flow. They wanted to avoid time-consuming and unnecessary tests. “One of the changes was to reduce our reliance on X rays for patients with neck injuries from, say, a minor motor vehicle accident,” says Olshaker. “There are certain criteria for patients with what we consider low-risk presentations, and if we can avoid getting unnecessary X rays, CAT scans, or bloods tests, that will significantly reduce the throughput time.”
But Litvak suspected that the overcrowding wasn’t only an ED problem. When the ED swelled to capacity, the staff were well equipped to handle the heavier flow. Overcrowding didn’t happen when patients swarmed in, but when a lack of available hospital beds prevented them from leaving the ED.
The bottleneck
Chessare and Litvak traced the traffic jam up to the hospital’s intensive care unit (ICU), where the sickest patients recover from surgery. “We found that the ICU is the real bottleneck for patient flow in the ED,” says Litvak. “They cannot get patients through the ED or the operating room when the ICU beds are filled.” This was especially evident on Wednesdays and Thursdays, when competition for ICU beds was intense. The problem, Litvak found, was that vascular and cardiac surgeons scheduled almost all of their elective cases on Wednesdays. “We saw these huge peaks in demand for ICU beds that made no sense,” says Chessare, who is also MED associate dean of clinical affairs and a MED professor of pediatrics. “So we worked with the surgeons to put a cap on them.”
That was a minor coup, Litvak says, because at most hospitals surgeons have autonomy in setting their own schedules in the operating room. But Chessare asked them to consider a radical change: scheduling elective surgeries more evenly throughout the week to avoid the peaks and valleys in the ICU. Most hospitals give individual surgeons fixed blocks of time every week to schedule procedures in the operating room, and it happened that the most complex surgeries were blocked out for Wednesdays. Litvak suggested switching to an open scheduling system, where surgeons book time in the OR only when they need to, with no more than two vascular cases a day. Under the new system, one of the eight operating rooms is set aside exclusively for emergency procedures, Litvak says, and that has dramatically cut down on the number of elective surgeries that have to be bumped to accommodate urgent cases.
Chessare points to Litvak’s theories on variability as the key to preventing traffic jams in the ED. In his research, Litvak has studied the ebb and flow of patients in hospitals and the factors controlling the varying patient demand. “You can’t control the rate at which people have chest pain and come to your ED,” says Chessare, “but you can control how long it takes to register the patient, to get a doctor to the bedside, to prepare an empty room for a new patient. Eugene has been asking that hospitals manage themselves much more scientifically and rationally, like other service industries do.”
A tighter ship
Chessare notes that emergency room overcrowding wasn’t a problem in New England until about 15 years ago, when hospitals began reducing the number of inpatient beds to cut costs. But demand for medical care in Massachusetts has steadily increased by 2 to 3 percent each year as the population continues aging. “As the demand has gone up,” Chessare says, “the inefficiencies in the system are now intolerable because we’re functioning at capacity for a certain number of hours each day. The first marker of this saturation is emergency room overcrowding.”
Overcrowding didn’t occur nearly as often 20 years ago, he says, because hospitals generally “staffed to the peaks,” maintaining facilities that were larger than necessary for the average demand. “Traditionally, hospitals have not managed themselves as scientifically as they might,” Chessare says. “Every other service industry in a competitive environment manages throughput and flow, because their goal is to serve more people to make more money. If they don’t serve more, and serve them faster, then someone else will figure out how to do it and they’ll go out of business.”
Working with Litvak, the BMC physicians are now applying for federal funding to continue their efficiency work on a larger scale. “It isn’t as if we got a grant, we fixed everything, and now we’re on the national speaking circuit,” says Chessare. “If you believe that performance improvement is the correct business model, you’ll never stop changing. You can always do better.”
22
October 2004
Boston University
Office of University Relations