ELIMINATING SILOS AND STANDARDIZING WORKFLOW TO IMPROVE LEFT BEFORE TREATMENT COMPLETED (LBTC) RATES
Post-Covid, three affiliated hospitals in the Southeast struggled to regain standard Emergency Department (ED) workflows, uphold its commitment to a “no-wait” ED, and maintain sound Inpatient (IP) throughput. The system included a 264-bed full-service facility with approximately 20,000 ED visits, plus two affiliated sites with smaller EDs.
The institution prided itself on a no-wait ED, but nursing leadership turnovers, physician attrition, and COVID-related challenges had significantly disrupted operations. Additionally, the IP process for discharging patients lacked structure and collaboration with Hospital Medicine (HM) leading to delays in IP bed availability and longer than expected IP LOS, measured in excess days. The system was operating on a principle of self-optimization, causing discrepancies in data use and sharing.
Left Before Treatment Completed (LBTC) rates far exceeded The Emergency Department Benchmark Alliance (EDBA) standard and were not meeting hospital leadership’s expectations. Core implemented processes to improve this key metric which included patients who left without being seen, signed out against medical advice, or eloped.
Core Clinical Partners undertook a multi-dimensional approach to address these challenges, focusing on building standardized processes, fostering transparency, enhancing leadership, and promoting collaboration.
Dashboard Creation & Data Analysis
A crucial initial step was the development of a comprehensive dashboard that provided key metrics for each of the three Emergency Departments. Core’s Medical Director collaborated with hospital leadership to gather data by facility and physician. Analysis of this data highlighted a significantly long Length of Stay (LOS) for admitted and discharged patients. Further analysis revealed a significantly higher LOS for low acuity patients, indicating a need for a specialized workflow process to manage these cases. A focused management of low acuity ED patients will decrease LOS in all patient dispositions.
Core had first recruited an interim Medical Director who was present upon the start of the contract. Then, following a nationwide search, Core added a permanent Medical Director who was appointed to oversee all three sites, significantly bolstering leadership effectiveness. In addition, Core’s strong recruiting efforts reduced the number of locum physicians, bringing additional continuity to staff which is critical to success.
Collaboration & Standardization
The Hospital Medicine (HM) team began to meet with Case Management daily, focusing on ‘excess days’ and working on standardizing multi-disciplinary rounds. These regular daily huddles were used to actively manage next day discharges, review the previous day’s metrics and turnaround times, and discuss anomalies or delays.
The meetings facilitated ongoing problem-solving and process improvement, ensuring consistency and continuity across the sites. Most importantly, the standardization of multi-disciplinary rounds led to a reduction in LOS by identifying barriers to discharge and ensuring patients safely and promptly moved to the next level of care.
Meanwhile, night-shift HM Advanced Practice Providers (APP) were given standardized workflows to prepare patients for discharge during their shifts, further streamlining operations for IP HM and freeing up IP beds for admitted patients waiting in the ED, thus reducing ED admission LOS.
Process Mapping & Workflow Development
Core organized and led a three-day Lean event, bringing together stakeholders from all departments. Current ED processes were mapped and evaluated for redundancy and waste, and future state processes were outlined. This resulted in a new ED workflow for low-acuity patients that was implemented across all sites.
The strategic and comprehensive initiatives implemented by Core Clinical Partners brought about significant positive change across all three sites:
THE NEWLY CREATED DASHBOARD, REGULAR DAILY HUDDLES, AND DATA-DRIVEN DISCUSSIONS IMPROVED TRANSPARENCY AND FOSTERED PROACTIVE PROBLEM-SOLVING AMONG NURSING, PHYSICIANS, CASE MANAGEMENT, AND OTHER ANCILLARY DEPARTMENTS.
REDUCED ED LOS FOR ADMITTED, DISCHARGED, AND LOW ACUITY PATIENTS.
LBTC RATES ACROSS ALL THREE SITES WERE HALVED, FALLING FROM MONTHLY AVERAGES SOMETIMES IN EXCESS OF 4% TO LESS THAN 2%.
HOSPITAL MEDICINE IP LOS ‘EXCESS DAYS’ DROPPED SIGNIFICANTLY FROM NEARLY HALF A DAY IN Q1 PRIOR TO THE LEAN EVENT AND NEW PROCESSES, DOWN TO CONSISTENTLY LESS THAN .25 DAYS AFTER.
Overall, Core Clinical Partners’ intervention transformed the system from one of many siloed teams to a cohesive, integrated, and efficient network, showcasing the benefits of data-driven decision-making, leadership enhancement, and standardized workflow in improving patient care and throughput.