Improvements in emergency department create ripple effect in hospital

Kennan Hospital and University Health Center, Sioux Falls, S.D. used a manufacturing concept called Lean to identify wasted steps in the delivery of care. The result: decreased wait times and more efficiency in a new emergency department.

Where: Avera McKennan Hospital & University Health Center, Sioux Falls, S.D.

The issue: Decreasing wait times and maximizing efficiency in a new emergency department.

Background: Avera McKennan, which sees about 25,000 ED patients annually, wanted to organize a new ED where patients could be seen as efficiently as possible, as well as improve patient care and satisfaction. Using a manufacturing concept called “Lean,” the ED analyzed every level of its operation and videotaped patient experiences and how the staff moved about. The results revealed “a lot of steps wasted and a lot of time wasted,” said Donald Kosiak, MD, medical director of the ED. The staff, for instance, gathered more information than needed in triage, asked patients to repeat their stories over and over, and spent valuable time retrieving supplies. The findings helped shape plans for the new ED, which opened in December 2007.

How it works: The ED, a Level II trauma center with 18,000 square feet (not including support space), is now arranged like a racetrack. Most treatment rooms have a door that opens to an outer hallway, which allows for the smooth flow of patients, family and others in and out, and another door opens to the core of the ED.

Sixteen of the ED's 19 rooms are universal—set up and equipped alike so that workers know exactly where to find everything. It's easier to stock supplies, and there's flexibility in assigning patients because the rooms are suitable for 85% of the cases that come in. Specialty carts, such as an eye exam cart, are brought in as needed.

Triage and registration were also revamped. The triage nurse gets only the basics—patient name, vital signs and symptoms—then directly assigns the patient to an available nurse. To further streamline information gathering and to jumpstart care, a doctor and nurse do the initial assessment together whenever possible. Once care is underway, the registration clerk goes to the bedside.

The challenges: The ED couldn't be studied in isolation. Making things run better meant understanding and improving on other services, too— from the lab to admissions. Staff needed to analyze a lot of data to see which days and times patients most often came to the hospital and which units they were admitted to.


  • The average wait for triage has been halved from 10 minutes to five. The average wait to see a doctor is now 20 minutes. (The hospital has no comparable data from before the reorganization.) The average overall time in the ED is two hours and seven minutes, down from two hours and 20 minutes. The nationwide average is four hours and five minutes, according to a 2008 Press-Ganey report.
  • The new system has reduced noise and frenzy, which has helped staff as well as patients. “I think people feel more relaxed,” Dr. Kosiak said. “The level of anxiety is down and you can feel it.”
  • Improvements in the ED have caused a ripple effect throughout the hospital. Jennifer McKay, MD, co-director of Avera McKennan's hospitalist program, said patients are now more likely to be admitted to the floors with scans already done and reviewed, and with a good care plan underway. “You decrease the length of stay, you make families happier and make things easier for the nursing staff,” Dr. McKay said.

Lessons learned: Changing how nurses, doctors and other ED staff do their work is not automatic. “Initially, it's hard to get that buy-in for change,” Dr. Kosiak said. “Everyone has their own idea of how things can be done differently.”

How patients benefit: Patients are seeing a doctor sooner, getting X-rays and lab tests more quickly, and going home faster. They and their families like the privacy afforded by the new layout of the ED, which ranks in the mid-90th percentile for patient satisfaction as measured by Press-Ganey surveys. The ED has also attended to creature comforts by installing a coffee bar/Internet café for family members.

Next steps: The hospital is applying design and efficiency lessons learned in the ED to other spots, including an admissions hub for patients admitted directly to the hospital and a new family practice center.

Words of wisdom: “Everyone who comes to the hospital just wants to know what's wrong with them,” Dr. Kosiak said. “If you have to wait in the waiting area for an hour and then you wait another hour and a half after they take you back, you get the sense people aren't taking you seriously.”