RWJBarnabas Health’s Successful ED Patient-Flow Transformation Initiative

The U.S. healthcare system survived the COVID-19 pandemic—with huge losses of human beings and a great deal of stress on clinicians and staffs in hospitals and clinics, of course. But once people were freer to pursue in-person care, emergency department (ED) volume began to rise inexorably, putting pressures of all kinds on health systems nationwide.

One of the countless health systems nationwide whose leaders have had to face up to a large rise in ED patient volume has been the 12-hospital, 5,455-bed West Orange, New Jersey-based RWJBarnabas Health, the largest inpatient hospital-based health system in the state, and one that encompasses 12 inpatient hospitals and one freestanding ED, with its service area extending from north to south across New Jersey.

RWJBarnabas Health sees 850,000 ED visits a year, and leaders at the health system came to the conclusion over two years ago that they needed to optimize care delivery and operational processes in their EDs both to improve the patient experience and also to make the health system more efficient overall.

Recently, Christopher Freer, D.O., senior vice president for emergency and hospital services at RWJBarnabas Health, spoke with Healthcare Innovation Editor-in-Chief Mark Hagland, regarding his leadership of an initiative to optimize patient flow and clinician workflow in the health system’s EDs. Below are excerpts from their interview.

Tell us how this initiative started, and what triggered it?

It started during the COVID-19 pandemic. Right after the first wave of COVID, we began to analyze how our different emergency departments were working. We had experienced some disastrous wait times during the pandemic; and so in 2022, we decided to do a reset. We had been experiencing long wait times, angry patients, and provider burnout, like everyone. So we have a collaborative where we meet, and at one of our sites, Cooperman Barnabas, the leaders in that ED started turning the corner in 2022-2023. Half the EDs were the right processes, based on our analysis, and so we helped the others move forward.

What was the optimal process that those leaders identified?

The thing is that what’s involved are actually simple things. It all comes down to patients first, patient-centered care. What I preach a lot is, control what you can control: how that patient arrives, what we do on arrival. You can have 15-20 patients walking through the door in an hour. Triage is not a place, it’s a process. One key element in success is that we put our most experienced nurses out in the waiting room. They know just by looking at you where to send you. There are different lanes. Need pediatrics? The main ED? And so on. We get information right away and we bring services to the patient right away, rather than focusing on getting to the final parts of the information-gathering process at the outset.

Had the triaging not been fast, effective enough prior to this initiative?

Honestly, too much information was being taken upfront. Doctors, nurses, and PAs [physician assistants] had to learn to see a patient without all the information and vital signs. You can get enough information from the initial triaging, and get the care started. What’s your name, Social Security number, and what are you here for? Instead of, let me package the patient so well that it takes 30 minutes per patient and creates a bottleneck.

So, as a result, you’re moving patients more efficiently now?

Yes, that’s right. Historically, there’s been a lot of downtime in the patient flow process. And during the downtime after the initial triaging, that provides us the opportunity to get further information. The absolutely key point is to move the patient as quickly as possible.

How did you advance the process from one ED to another inside the system?

We already had the data; we made it more transparent. Every ED chair and nurse manager sees all the data from all the EDs. And they’re competitive. And nurses and physicians are sitting next to each other doing this. So this is physicians and nurse leaders viewing each others’ pain points in real time. And we had “SWAT teams” going from point A to point B, explaining how they did this. In some cases, it was a six-month project. Some took two or three months, some took six months. So we already had the data and brought a team to you. And I recently went to a hospital recently and saw they weren’t doing this. I actually walked up to registration, and said, tell me what you do here. And they were taking too much information initially.

The key is that you have to set the process in place. If you put good people into bad processes, you’ll have bad outcomes. So accountability, transparency, and you’re relentless. And after a while, it becomes the flywheel. People get excited. At nursing huddles, people were getting excited. It becomes a cultural change.

What kinds of clinical culture issues had to be addressed?

I’ve been an ED doctor for a long time. And because of my role, I have a seat at the table with the corporate folks. We pushed down from the CMO, CNO, CEO, in each facility—our COOs get all these dashboards. And an efficient ED is a reflection of an efficient hospital. There was a cultural shift across the organization around this. Our Achilles’ heel was admitted patient flow, and that springs from the ED. If you have a patient with a pulmonary embolism and pneumonia and that multiplies, you’ve got an equation problem. An ED really has a front end, middle, and back. The front end is under our control. To manage the back end, we have to partner with the inpatient folks. Let’s start there. And then we worked also with the back end. And we have a couple of hospitals that struggle with the back end. We have APPs who are on a shift, and they’re virtual. Patients can get a virtual provider. They can see six to ten patients an hour; they can get processes started.

And, through the information-gathering process, a couple of complaints stuck in my head. One is, I wish they would ask me how I’m feeling. I was in an ED with my daughter and saw this. The other was our assistant CFO with his daughter. Can’t you do something else for me? And we have staff that wants to do virtual work; we just have to figure out how to use that staff. We’ve seen over 20,000 patients virtually. It helps support our process.

How have you been able to analyze the data to improve processes?

I’ve sent provider incentives based on quality and financial data. You can provide incentives, and sites have gotten competitive around those incentives. And when I send this to the providers, that creates the culture of, wow, I work at a place that’s doing good stuff. It has a flywheel effect. You want them to believe it. You set the process. And you explain to the doctors and nurses why you need to do it a certain way. And patient experience scores go up because they’re not waiting as long.

What have been the biggest lessons learned?

I’m fortunate; I have 12 ED chairs who report to me, and we all meet together. Collaboration is critical. You start thinking together and stealing ideas from each other. And you have to have your nurses at your right-hand side, as physicians. It’s like a dance you do together. And emergency medicine—I started residency in 1995. I don’t think it’s changed that much except that the acuity has increased. But the patient flow processes haven’t really changed. This is really about being relentless, being driven, and working together collaboratively with your nursing team. And we’re not perfect. We have issues. I also oversee the hospitalists, and we’re doing a lot of work with lengths of stay, interdisciplinary rounds, early discharge, etc.

So the transformation is about process and culture, correct?

Yes, and it’s also about teamwork with your nursing team. No one comes to work to not do it well. People want to do the right thing, but it’s hard to convince them to change. But the results have been terrific; we reduced the time from putting in an inpatient admission order to a head in a bed, by 37 percent by February of 2024. I should also note that we had been on four different EHRs until two years ago; the last transition was a year ago, and we’re all now on the Epic system, which makes data-sharing so much easier.