Using the online and offline change model to improve efficiency for fast-track patients in an emergency department.

BACKGROUND In 1998 the emergency department (ED) Work Group at Johns Hopkins Bayview Medical Center (Baltimore) worked to reinvigorate the fast-track program within the ED to improve throughput for patients with minor illnesses and injuries who present for care. There had been two prior unsuccessful attempts to overhaul the fast-track process. METHODS The work group used a change model intended to improve both processes and relationships for complex organizational problems that span departments and functional units. Before the first work group meeting, the work group evaluated the institutional commitment to address the issue. The next step was to find data to fully understand the issues and establish a baseline for evaluating improvements--for example, patients with minor illnesses and injuries had excessively long total ED (registration to discharge) times: 5 hours 57 minutes on average for nonacute patients. ONLINE AND OFFLINE MEETINGS: The work group identified process problems, but relationship barriers became evident as the new processes were discussed. Yet offline work was needed to minimize the potential for online surprises. The work group leaders met separately in small groups with nursing staff, lab staff, x-ray staff, registrars, and physician's assistants to inform them of data, obtain input about process changes, and address any potential concerns. The group conducted four tests of change (using Plan-Do-Study-Act cycles) to eliminate the root causes of slow turnaround identified previously. RESULTS Total ED time decreased to an average of 1 hour 47 minutes; the practice of placing nonacute patients in fast track before all higher-acuity patients were seen gained acceptance. The percentage of higher-acuity patients sent to fast track decreased from 17% of all patients seen in fast track in January 1998 to 8.5% by February 1999. Patients with minor illnesses and injuries no longer had to wait behind higher-acuity patients just to be registered. The average wait for registration decreased from 42 minutes in January 1998 to 14 minutes in February 1999. Physician's assistant, nursing, and technician staff all report improved working relationships and feeling a team spirit. DISCUSSION The offline component of the integrated model helped to improve organizational relationships and dialogue among team members, thereby facilitating the effectiveness of online efforts to improve processes. This model has also been applied to improve patient registration (revenue recovery) and the emergency transfer and admissions process.