Four years ago, the emergency department at Overlook Hospital was plagued by long waiting times and slumping patient satisfaction.
Today the number of patients seeking treatment in the ED is up, waiting times for many treatments are down, and the ED's rating in one national patient satisfaction benchmark survey stands at 99 percent. Furthermore, all changes were implemented without costly personnel additions.
Although he's reluctant to accept it, many at the Summit, N.J., hospital give credit to James Espinosa, M.D., medical director of the emergency department and chairman of emergency medicine.
"I'm no more responsible for when it was low than I am deserving of merit for when it goes high," says Espinosa, 44. "This work cannot be done by doctors alone. You should sooner imagine you were going to fly than imagine you're going to re-engineer these systems by yourself."
Overlook is part of the three-hospital Atlantic Health System. The not-for-profit hospital has 490 acute-care beds and 1,969 employees. Espinosa directs 11 doctors, all independent contractors.
For its efforts, the Overlook emergency department received several awards, including the 1999 New Jersey Society for Quality Award; the 1998 Press, Ganey Award; the 1998 American Society for Quality Recognition; and the 1997 and 1998 American Hospital Association Society of Ambulatory Care Professionals, Ernst and Young Awards for Process Re-engineering.
In most emergency departments, the majority of resources are directed at the admitted patients. At Overlook, staff began spending more time and energy working with patients who are directly discharged from the ED. Staff members use models of knees and ankles to explain common injuries and give patients their business cards that list phone numbers to call with questions.
The result was a program dubbed "Fast Track." Patients can be out of the emergency department with simple problems such as sprained ankles within an hour. The average turnaround for a patient with a simple problem dropped from 90 minutes to 47 minutes.
Under Espinosa's direction, Overlook's Fast Track program reduced waiting time, increased resources for discharged patients, reduced X-ray cycle time and created a pediatric treatment area and a children's corner in the waiting room.
In addition, privacy was increased in the registration area by adding soundproof dividers at the registration desks.
With minimal funds, the emergency room was outfitted with brighter lights and new wallpaper, Espinosa says.
Sixty percent of all ED patients required X-rays, adding 72 minutes to the process. Overlook's cycle is down to 24 minutes.
The department decreased time to thrombolytic treatment for heart attack patients from 60 minutes to 16 minutes, which became a National Institutes of Health benchmark. Espinosa felt the best way to approach performance improvement was through clinical processes. He co-chaired the NIH's Chest Pain Performance Improvement Team, which was designed to reduce heart attack patients' waiting time for thrombolytic treatment.
Patients defined an aspect of quality as quick access to a physician. Overlook reduced how long patients wait to see a doctor.
Four years ago, Espinosa's son developed leukemia. "I became sensitized to events from the patient's perspective," he says. His son, who just turned 5, is doing well.
Patients and their families, including Espinosa, don't want to complain and want to be "good patients."
But Espinosa says patients have a right to expect prompt and courteous treatment, regardless of the department.
Hospitals across the country have tapped into Overlook's ideas and picked Espinosa's brain on how to improve emergency care.
Making the changes was the most difficult teaching Espinosa says he's done.
"There are lots of physicians who just don't get it. I, as the speaker, become the target for their frustrations and feelings of loss of autonomy, their senses that the data isn't appropriately adjusted for the severity and risk in the system."
That's often people's reaction to poor results, says Mel Hall, chief operating officer at Press, Ganey Associates, which was brought in to work with Espinosa and the Overlook staff on improving patient satisfaction in 1995.
"Most people either try to shoot the messenger or try to figure out why it's not an accurate reflection," Hall says. "Dr. Espinosa and his team took the message and said, 'This is what patients are saying about us, and we don't like it.' "
The emergency department showed significant improvement in a recent satisfaction survey, jumping into the 90th percentile in a variety of categories. Such a leap is "very unusual," Hall says.
Espinosa emphasizes it was the team that made the changes.
"I have mixed emotions about the award," he says. "It's all very lovely. It's a testimony to the ability to play well with others. My contribution has to do with understanding industrial quality and applying that. At the end of the day, you still need other mammals to work with you."