Every Minute Counts

Every Minute Counts

Business of health care by Matt Walsh | Editor

Sarasota Memorial's 30-minute guarantee in the ER wasn't a marketing gimmick. It was like moving the QM2. But it changed the hospital's entire organizational culture - for the better.

When Gwen MacKenzie, chief executive officer of Sarasota Memorial Hospital, announced the hospital would guarantee its emergency room patients they would be seen in 30 minutes or less, MacKenzie's peers in the industry and many among the hospital's staff thought she was crazy.

Conventional wisdom held if there were any guarantee, this would be a guaranteed failure.

It sounded like a great marketing ploy, a strategy to raise the public's awareness of the hospital and to signal that MacKenzie, in her job for a year, was taking action to lift the hospital's high national rankings even higher.

If that was the plan, the ER was a good place to draw attention. After all, Sarasota Memorial's emergency room touches the lives of 80,000 to 85,000 patients a year, the second-busiest ER on the west coast of Florida. And in many instances the ER is the first place patients experience the hospital. To a great extent, a hospital's reputation often rides on how patients are treated in the ER.

The 30-minute guarantee was much more than a marketing gimmick, though. As it turns out, it was a bold, far-reaching business decision. In reality, the guarantee has changed the entire operating culture of Sarasota Memorial, a 3,000-employee, $410-million business enterprise.

MacKenzie jokingly compares the implementation of the 30-minute guarantee to turning the QM2 - as if she and the hospital staff grabbed a rope and tried to pull the world's largest ship in another direction.

It wasn't easy. But in the industry, MacKenzie's move will stand as a successful case history in organizational management.

Time and money

Every minute counts in a hospital. There's this, too: Time is indeed money.

This is true not just in the emergency room or operating rooms of a hospital. It's true with every aspect of a hospital's complicated operations. Every department of the hospital is interconnected, and what happens in one department filters into another.

Think of it in terms of the domino-effect song - the heel bone is connected to the leg bone; the leg bone is connected to the hip bone; the hip bone is connected to the back bone ... etc. When one of those goes bad, it has repercussions throughout the body.

So it is in the hospital industry, a business that is notorious for its inefficiencies.

To make SMH more efficient, and thus save money, cut costs and improve patient satisfaction, MacKenzie decided the best place to start would be with the ER. She knew the 30-minute guarantee would not just make the emergency room staff work more efficiently. It also would force every section of the hospital to improve efficiencies as well.

Dr. Bill Colgate, Sarasota Memorial's medical director of emergency services and an ER doctor at the hospital for 13 years, had his doubts about the guarantee. As Rick Baxter, an ER volunteer put it recently, many nights in Sarasota Memorial's ER it's so busy "it can be like Calcutta in here."

In a 24-hour period, it's common for Sarasota Memorial's ER to see 225 patients. All of them are funneled through 52 ER patient rooms - roughly four patients per day per room.

But the flow of patients is anything but a steady, even flow. It's random. On a Friday night in October, the 52 beds were always occupied in a six-hour period between 4 and 10 p.m. But if, say, there was a sudden rush, with 20 people entering the ER in an hour - a common occurrence on Fridays - seeing that crush in the 30-minute window would be a challenge, especially considering the average stay in the ER is about two hours and 10 minutes.

Team effort

When MacKenzie announced the 30-minute strategy, Dr. Colgate and his colleagues knew success would depend not only on his fellow ER physicians working efficiently. The entire hospital staff would have to respond.

To get a patient out of the ER faster would require X-ray results to be read and transmitted back to the ER and to patients' private physicians faster. Blood test results would have to be produced faster. If an ER physician decided to admit a patient, the rooms in the hospital's overnight wings would have to be prepared faster. The room assignment techs would need to know at all times which wings were ready and which ones had enough nurses on the floors. Housekeeping would need to change the ER bedsheets faster. ER techs would have to transport patients to the the X-ray and hospital rooms faster.

All of this required departmental meetings of skeptical managers whose initial instincts were to protect the status quo.

When the blood-lab staff heard it would need to turn around tests faster, MacKenzie says, the staff's first response was: "We're going to need 10 more people."

Instead, they devised a simple coding system. All blood-test orders are transmitted to the laboratories through a pneumatic tubes. Because every order came in a black tube, the lab staff never knew which orders took priority. Decision: All ER lab orders were put in red tubes. They get priority.

The 10 people were not hired.

One transportation manager said there weren't enough wheelchairs in the hospital to transport ER patients. It turned out the hospital was using many of its wheelchairs to transport dismissed patients out of the hospital to their cars in the driveway. This created a shortage in ER.

Now the hospital lets patients walk out on their own. MacKenzie said since the change only one patient has commented negatively.

With a new emphasis on efficiency, the hospital has cut its patient transport time from 36 minutes to 30 minutes. This is big.

The hospital typically transports 350 patients a day from rooms and the ER, to and from the X-ray lab and to and from surgery. That six-minute savings on an annual basis could be translated like this: 12,775 hours a year saved. At, say, the cost of a medical tech earning $13 an hour, that's a $166,075 annual savings. Small in the overall scheme of the hospital, but when similar savings are gained in other departments, the money adds up.

Here's another efficiency improvement: In the old days, a decade ago, if an ER physician requested the health history on a patient, a runner would dash to the records department and bring them back in a cart. Today, patients' complete records are available on computer.

When Dr. Colgate peruses the spreadsheet of patients in the ER's treatment rooms, he routinely searches the patients' medical history. He likes to know how many times a patient has been to the ER. On that Friday night in October, just before checking on a 46-year-old woman with chest pains, Colgate calls up her history on the ER's computer screen: "This one has insurance," he says, "but she has been in the ER 13 times since '02."

Another improvement: Today, when the X-ray department has finished reading a patient's X-rays, a happy-face icon lights up on the computer screen spreadsheet by the patient's name. There is no more wondering when they'll be ready.

That same computer screen also displays when a patient was clocked into the ER and how long he has been waiting. Colgate and his physician-assistant colleagues constantly check the screen to monitor how much time they have to meet the 30-minute guarantee.

Improved atmosphere

Another logistical improvement: The ER now has greeters for patients as soon as they walk in. In the old days, nurses juggled the tasks of acting as in-take administrators and treating patients. Family members constantly barraged the nurses with questions about the status of patients. With the greeters and waiting room apart from the treatment rooms, nurses now can focus on treating patients, leaving the questions to the greeters. That has lifted a huge burden and changed the ER's atmosphere.

"You don't see anyone running and shouting anymore," Colgate says.

Indeed, on that Friday night in early October, Sarasota Memorial's emergency room displayed no signs of the frantic eruptions of NBC-TV's popular show, "ER." Says Colgate: "Medically, they are pretty darn accurate." But the TV drama, at least on this Friday night, appeared to be the antithesis of the quiet, earnest atmosphere of Sarasota Memorial's ER.

Colgate says the 30-minute guarantee helped change the ER's atmosphere. "It brought a lot more focus to everyone."

The results have been tangible. "We've squeezed out the non-value-added time," says Dr. Holland.

Since beginning the guarantee almost a year ago, the success rate has hovered around 75%. But the average length of stay for patients who ultimately are dismissed from the ER has fallen from 167 minutes to 130 minutes. In a year's time, that's a savings of roughly 49,333 hours of non-value-added time. And even if you put a minimal price tag of, say, $20 an hour on that time, Sarasota Memorial's 30-minute guarantee will have saved the hospital, conservatively, about $1 million in a year.

For Dr. Holland, the 30-minute challenge "has been a job satisfier. The ER is the best it's ever been," says Holland. "Not to mention, it has made it better for the patients."

New ER to feature fish, live music

When Sarasota Memorial Hospital's new emergency room opens in early November, patients and their family members will see an ER that doesn't come close to resembling that of the popular television show.

For one, it will be much quieter.

The new ER will feature an 800-gallon aquarium from Mote Marine Laboratories. Chief Executive Officer Gwen MacKenzie says family members and patients should also expect to see periodic music performances by members of the Florida West Coast Symphony.

The ER waiting rooms will be cozier, too. "We're going to have smaller waiting areas, so they're not like bus stations," MacKenzie says.

And, here's the biggie: The waiting rooms will no longer have televisions. MacKenzie says she chafed at the screaming TV talk shows that always seem to be blaring on full blast. As a compromise, the new ER will have TVs in each of the patient treatment rooms.