The Doctor Will See You Now. Really!

By Michael Weitekamp, MD

I don’t like to wait; who does? If I have to wait, it helps to know why and how much longer. It helps even more if I have something to do, to read, to listen to, or to watch – praise the smartphone! Disney also knows this: They don’t like hot, sweaty, whining kids any more than parents do. That is why wait times for rides at Disney World and Disneyland are posted; video monitors offer some distraction from the tedium. Even better, you can now get those magical FASTPASS tickets that allow you to return during a certain time window and basically go right into the attraction. You feel more in control because you are off doing something else while actually “waiting” to enter Space Mountain!

I don’t have hard data on this, but I would guess not many folks die while waiting on line at amusement parks, even if at times you contemplated death as the lesser of evils while baking in the hot sun, hungry, tired, and hours away from an adult beverage. However, waiting in an emergency department can be a fatal event. These stories are fortunately infrequent, but probably should be considered “never events.” Even if you do not die while waiting in an ED, your care may be compromised in other ways. You may register, but leave without being seen or treated; that would make you an LWBS or a LWOT statistic. You may simply gasp at the mass of unhappy and unwell humanity overflowing the waiting room, do an about-face and bolt; that would make you a “peek and shriek.” None of this makes for good patient care, risk management, or customer satisfaction.

Does it have to be like that? Staff at the Penn State Hershey Medical Center Emergency Department certainly didn’t think so. Their story is a great example of necessity being the mother of innovation. Facing tremendous growing pains a few years back, handling more than 50,000 visits in a space designed for 30,000, the ED featured long wait times, “door to provider” times of more than 90 minutes, 7-hour average stays, LWOT rates approaching 10 percent, and plummeting patient satisfaction. ED staff knew something creative had to be done, but within significant capital constraints for new construction.

Working with colleagues from the College of Engineering, Chris DeFlitch, MD, vice chair of the ED, and now also CMIO for Penn State, meticulously mapped care processes, workflows, time to task completion, and space utilization. Using Lean concepts, DeFlitch and his team eliminated many of the “non-value-added” steps in an ED visit. One step with no value was waiting for the sake of waiting.

DeFlitch developed the technique known as PDQ, “physician directed queuing.” In this innovative approach, the triage phenomenon simply happens simultaneously with initiation of definitive care, and sometimes serves in and of itself as definitive care. So instead of being sent back into the waiting room, based on nursing assessment, you may be cared for and discharged. For example, Dr. DeFlitch tells the story of a child presenting with a bead stuck in her nose. Dad had tried to get it out at home without success. Within 9 minutes (yes, NINE minutes) the family presented for care, was seen by the nurse and physician, received instructions, and was discharged.

The technique was piloted in the old physical plant and demonstrated significant systems improvements in LWBS, wait times, door-to-doctor time, and just about every quality measure. Using this process as the driver, DeFlitch worked with construction and design teams to create and build an ED expansion that eliminated the waiting room, and saved Penn State nearly $13 million in capital expenses.

Partnering with the nurse manager and the medical director, Glenn Geeting, MD, the innovation was operationalized and managed in the ED expansion space. “We wanted to prioritize the patient and family-centered care approach, while opening beds for patients who really need them,” says DeFlitch. If you are seriously ill and/or unstable, you get a bed and definitive care begun immediately.

There are still occasional times where rooms are not available, due to admitted patients awaiting placement in the hospital (boarders). To accommodate the wait for an ED bed, DeFlitch created private waiting space internal to the ED. Because care is initiated on arrival, while the patient may be waiting for a traditional ED bed, care has been started.

Intense process and workflow improvement allowed Penn State to accommodate larger volumes with modest reconfiguring of existing space, limited expansion of new space, and minimal capital outlay. Best of all, provider and patient satisfaction has improved, ranking near or at the top of UHC rankings: door-to-provider time below 20 minutes and total dwell time dramatically reduced. LWOTs are as rare (0.4 percent) as black swans, and the waiting room is gone. Really! It’s not there anymore. All you will find in front of the arrival area are a couple of chairs in the event someone needs to sit down before they faint when they find out there is no waiting room!

This is a great example of how academic medical centers can harness the interdisciplinary, intellectual horsepower of their universities to direct focus on solving health system problems. Penn State has created the Center for Integrated Healthcare Delivery Systems (CIHDS) to develop and support this kind of interdisciplinary thinking being done at Penn State and elsewhere. It can and should be done everywhere.

—Michael Weitekamp, MD, MHA, FACP is a Professor of Medicine at Penn State College of Medicine and a Robert G. Petersdorf Scholar at the Association of American Medical Colleges. He can be reached at mweitekamp@aamc.org.