Improving Emergency Department Performance Through Simultaneous Operational and Cultural Enhancements

Background and Objective: Emergency departments (ED) receive significant scrutiny regarding their function and processes, as the ED is typically the initial hospital entry point for patients. Process improvement initiatives have been shown to improve ED performance metrics. However, these initiatives are often carried out as individual projects rather than comprehensive program redesigns. Therefore, this study aimed to determine if a novel model created with the principles of design-thinking improved patient experience and flow metrics in several EDs within a hospital system. Methods: A multi-faceted approach was developed focusing on both culture and performance within 7 EDs. The PEOPLE+ model was developed, which comprises 5 key areas of focus: philosophy, economics, operational architecture, providers, and leadership. The PEOPLE+ model served as the framework that prioritized all providers, supported staff, optimized patient care, and embraced adaptability and continuous improvement. Left without being seen (LWBS), left against medical advice, emergency medical services volume, diversion hours, visit volume, patient experience, admit volume, length of stay (LOS) discharged, LOS admitted, median door-to-provider time, patient door to provider time <30 minutes, total transfers, total boarders, and total boarder hours were compared 22 months before to 24 months post-implementation. Results: Following the partnership, there were statistically significant improvements in LWBS (−80.0%; P < .001), leaving against medical advice (−17.6%; P < .001), diversion hours (−95.6%; P < .001), patient experience (+250.7%; P < .001), LOS discharged (−24.2%; P < .001), LOS admitted (−16.9%; P < .001), median door-to-provider time (−55.2%; P < .001), and patient door to provider <30 minutes (+51.5%; P < .001). LWBS (−47.4%; P < .001), diversion hours (≤−84.6%; P ≤ .025), and median door-to-provider time (≤ −31.3%; P < .001) during the second, third, and fourth post-6-month time frames were significantly lower compared to the first 6 months following the partnership, whereas leaving against medical advice (≤−27.8%; P ≤ .013) and LOS discharged (≤ −12.8%; P ≤ .042) during the third and fourth 6-month time frames were significantly lower compared to the first 6 months following the partnership. Conversely, patient experience (≥ +36.5%; P ≤ .040) and patient door-to-provider <30 minutes (≥ +18.1%; P < .001) during the second, third, and fourth 6-month time frames were significantly greater compared to the first 6 months following the partnership. Conclusions: Changes to philosophic, economic, operational, leadership, and staffing models highlighted by provider ownership and direct provider involvement in developing and executing changes allowed ED performance metrics to significantly improve.