CREATING A NO-WAIT EMERGENCY DEPARTMENT
With the release of three reports by the Institute of Medicine early last summer, the rest of America learned what those of us in the healthcare industry have known for some time: Emergency departments are in a nationwide crisis. The product of a two-year analysis of the nation's emergency care system, the reports (available at http://www.iom.edu/CMS/3809/16107/35007.aspx) conclude that too few hospital beds and too many uninsured or underinsured patients using the ED as their primary source of healthcare have pushed the system to the verge of collapse. It's a problem that many industry leaders and politicians are now trying to address before they're faced with a devastating emergency.
Emergency departments have become the nation's most expensive waiting rooms, which is exactly what Seattle's Swedish Medical Center wanted to avoid in building Washington State's first freestanding emergency department in Issaquah, a Seattle Eastside suburb. In opening the Eastside Specialty Center—which houses an 18-room ED, diagnostic services, clinics for pediatrics and family medicine, and a sleep lab—Swedish aimed to establish a strong foothold in an affluent market historically dominated by a competitor. The window of opportunity, however, was narrow: By the time Swedish came to Callison, only 11 months remained to design and construct the facility (which, by the way, needed to provide a customer-friendly experience characterized by prompt, private care in an environment guided by the tenets of evidence-based design)
Creating a no-wait emergency department is a tall order by any standards. Having to pull it off in less than a year—in a former office building—was cause for alarm. We tried not to panic. We resisted the impulse to simply “do what we knew” as a means to achieve acceptable, if not exceptional, results. Instead, absent the luxury of time, we did what any good doctor would do in an emergency: We triaged the situation. The result was an innovative design protocol that yielded a revolutionary planning concept in a very short time. This, in turn, gave Swedish a stake in the Eastside market that was 60% greater than they had projected for the first month of operation.
This was achieved through a series of daylong “facility-triage” sessions, with mandatory attendance by all team members. The client agreed to three rules of engagement: Make the project a priority, give decision-making authority to those in the room, and do not retreat. The process, which we call “architectural improv,” was so successful at generating strong ideas and group buy-in that we've made it a regular part of our practice. Here's how it worked on the Swedish emergency department project
Set the scene. First, we established the basics of who, what, where, when, and why. Key players representing every aspect of facility-related healthcare delivery were identified. As a group, we documented existing flows of people, process, and materials (the real) and determined desired outcomes (the ideal), to provide a baseline of information and a target to design toward. This, in turn, allowed us to track progress and practice our “do not retreat” mantra.
Assign roles. We assigned roles and stuck to them like glue. For example, I represented only the “human point of view” and thus banished all thoughts of budget, schedule, care teams, or administrators from possibly compromising my perspective. Other team members were accountable for those other perspectives (including materials management, IT and diagnostic imaging).
Enjoy the show. This isolation of roles had a remarkable effect: In the midst of a frenzied schedule, it gave each team member space to think. Filters disappeared. Ideas emerged undiluted. Everyone had a say. Expectations were realigned. And, before long, an innovative concept took shape that would literally take the wait out of the ED.
Essentially, Swedish Medical Center's Issaquah emergency department feels like a clinic but functions as an operating room. The key to its success resides in two factors: the elimination of the waiting room and a clear boundary between and on- and off-stage activities.
Appropriately, the planning diagram looks literally like a life preserver. Picture the hole of the life preserver as the center of activity for care teams. Patient rooms comprise the ring itself. Families can wait outside the ring, adjacent to their family members' rooms. Generous circulation paths allow access to the patient from both the center and the outside of the ring. This configuration eliminates the congestion typical of emergency departments while allowing care teams and families to converge with the patients without getting in each other's way.
Upon entering a small lobby, or sometimes even before they enter the building, patients are given a rapid professional assessment to determine their condition, after which they're immediately taken to a treatment room for triage, registration, and examination. Small, wireless-equipped activity areas outside each room maintain privacy, and exam rooms are sized to accommodate family who can lend support without being underfoot. The rooms also include Internet access for patients and families who wish to learn more about their health issues.
With a plan that supports immediate reassurance and action, including greeting and escort to a room on arrival and convenient Internet access—the Eastside Specialty Center is designed to provide patients with a sense of control over their situation. The provisions for privacy and family support space also lessen patient anxiety. Rich colors and textures throughout the space provide visual interest, and all patient rooms have access to daylight. The same careful consideration of design elements in the off-stage areas supports and empowers the care teams.
The Eastside Specialty Center opened in March 2005. Since then, progress on its quality and service goals has been exceptional. A care team member sees patients immediately upon arrival; Swedish guarantees that patients will see a physician in 30 minutes or less, with most being seen within 10 minutes (a result that has been documented). This guarantee—coupled with the facility's environment, patients' experience, and the quality of care—has pleased the community, increased care team effectiveness, and continues to fuel patient satisfaction, currently being monitored by ongoing studies.
The mental “elbow room” and clarity we gained were two extraordinary benefits we couldn't have predicted in using a process developed purely as a time-saver. In reflecting on why it happened and how to replicate it, we realized that, yes, the urgency of this project's schedule forced everyone on the team to give up a part of themselves in the name of achieving a larger goal. But the real lesson, as I see it, rests not so much in the sacrifice itself, but that in giving some things up, we all gained far more than we ever could have imagined.
In approaching the Eastside Specialty Center in a nontraditional way, not only did we not retreat, but we took a giant leap forward in redefining the ED experience as a more efficient and more humane event. Will it solve America's emergent care crisis? No, although I know it will do much to resolve the operational, image, and medical challenges associated with overcrowding in this specific community. But our discovery demonstrates an important point that will be critical as leaders work on the far more urgent need to overhaul a badly compromised healthcare system: We can't expect new ideas to emerge from old ways of thinking. We need to step out of our everyday roles to gain perspective and insight. Sometimes, all we need is a little more space. HD