Studer Spotlight: Rethinking Emergency Department Results: Are You Treating Before Diagnosing?

Posted on Wed, Jul 20, 2016
Studer Spotlight: Rethinking Emergency Department Results: Are You Treating Before Diagnosing?

Since 2010, EmCare has maintained a strong partnership with Studer Group to improve clinical and operational results for our client hospitals. As a result of this partnership, Studer Group has provided access to exclusive content only available on Each month, one of Studer Group's insightful articles will be made available to blog readers. For more information about EmCare's partnership with Studer Group, click here. For more exclusive content, including webinars, learning labs, networking opportunities and more, visit

By Karen Smith, MSN, RN, CEN, NE-BC

Would you ever start an antibiotic without having a diagnosed infection? How about having a cast applied before the X-ray is taken? We expect to be examined and a diagnosis made BEFORE starting any prescribed treatment. The same approach should be taken when identifying ways to improve Emergency Department (ED) results.

Have you ever wondered why your ED does not seem to have efficient processes? Do your goals for the department seem elusive and unattainable? Are you concerned that the engagement of your staff is not where you want it to be? The problem may be that you aren’t addressing the right problems, or you are trying to treat a problem before properly diagnosing.

With many ED volumes rising1, EDs and healthcare organizations must develop and implement the right tools and skills to drive results.

Our Studer Group Emergency Department experts use a diagnostic approach to determining the individual needs of an ED. This precedes the formulation of the treatment plan and consists of four key steps:

  1. Assess: The first step is to conduct a comprehensive assessment of the operational flow of the ED. This includes direct observation of patient movement, review of key operational metrics, staffing patterns to match patient volumes, overall productivity, and patient survey responses.
  2. Align goals: The next step is to determine goals for the ED and how those goals will be measured. The leaders must be in agreement of the vision for the department and setting goals that align with that vision. These are the building blocks for an objective evaluation system, such as Leader Evaluation Manager® that holds leaders accountable for achieving and exceeding their goals.
  3. Align behaviors: There are certain behaviors and tactics that drive results in the correct direction. Expecting ED staff to change patterns or habits can be hard. Careful sequencing of change implementation must be accompanied by a large dose of the ‘why’ or the evidence-based reason to change. Teams will not see the full results of these changes without ensuring each are hardwired (have become habits).
  4. Align processes: Using the observed patterns and existing ED flow metrics vs. known best practices will help teams to determine which flow models need to be implemented. Splitting the flow of patients and processing them based on their assessed acuity level will ensure that every patient receives excellent care in as timely a manner as possible.

Let’s look at an example: If an ED wants to assess and treat a higher-than-average rate of patients leaving without being seen, the four steps might look like this:
  1. Assess: Examine the reasons why the rate is elevated based on triage process flow from arrival to being seen by a provider. Key metrics may indicate prolonged door-to-provider intervals or longer-than-average lengths of stay. Analysis of staffing to match arrival patterns must be considered as well as the efficiency of key interdependent departments.
  2. Align goals: Setting goals for improvement might include reducing the overall percentage of patients leaving without being seen and also the return-on-investment resulting from captured revenue. Leaders can then formulate specific action plans to focus their attention on the goals.
  3. Align behaviors: Our approach and communication to patients as they wait to be evaluated by a provider will directly and positively affect their willingness to wait and their overall satisfaction.
  4. Aligned processes: Implementing best practices for expedited triage and direct bedding can reduce the time interval of arrival to being seen by a provider. Other process tactics to implement could include placing a provider in triage or use of a results pending model.

Remember to connect back to the ‘why’? Reducing left-without-being-seen (LWOBS) will improve patient safety and satisfaction, increase revenue, and reduce risk when patients leave without evaluation. Plus, it will save ED staff members’ valuable time.

The results of this approach are staggering. For example, in one organization coached by Studer Group, a decreased overall LWOBS resulted in an annual savings of $289,000. In another Studer Group partner organization with an ED volume of 120,000 patients, LWOBS rates decreased by more than 50 percent resulting in an ROI of $6.4M in increased annual revenue.

High-performing EDs have mastered efficient patient flow using foundational behavioral goals and behaviors. As EDs are the front door to most hospitals, our patients deserve an evidence-based approach to their clinical care that is based on a diagnostic workup. Additionally, patient flow through the ED is also positively influenced by evidence-based processes that are part of a comprehensive treatment plan based on diagnosis.

ED providers and staff make a difference every day in the lives of patients and families. By putting these steps into place, the life you save may someday be your own!

1 ER Visits Continue to Rise Since Implementation of Affordable Care Act. American College of Emergency Physicians, May 4, 2015.

Studer Group Karen Smith

Karen has over 35 years of clinical and administrative experience, primarily in emergency departments. As a Certified Emergency Nurse and a Nurse Executive – Board Certified, she maintains an expertise in emergency care and nursing administration recognized by professional organizations.

Prior to joining Studer Group, Karen served in clinical staff roles for many years in both a Level-1 trauma center and community hospital settings. Her 10 years of direct leadership experience were at a Magnet hospital within a major hospital system in Rhode Island. During these leadership years, Karen coached staff to improve the patient experience, achieving patient satisfaction scores for nurse measures consistently in the 90th percentile or better. As an emergency department consultant, she held numerous emergency department leadership positions where she implemented measures to improve the patient experience, reduce numbers of patients leaving without being seen, and reduce door-to-provider intervals among other throughput measures.


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