The Birth of an Idea

Who is Dr. Jeff Dreyer? 

Jeffrey R. Dreyer, MD, MBA, FACEP is a Board-Certified Emergency Physician with over 15 years of practice experience. As a physician, his frustration with delayed patient care and deteriorating eyesight in 2001 forced Dr. Dreyer to reevaluate his place in the medical field and the emergency room. He obtained Six Sigma and Lean Certifications and received an MBA from the University of Tennessee, with a focus on patient throughput and health care cost containment. In November of 2007 Dr. Dreyer received the prestigious Excellence in Innovation award for outstanding achievement in support of excellence in care experience. 

Dr. Dreyer set out to find an answer. In 2012 he began to analyze the problem following the standard analysis of patient flow issues. He discovered that the standard approach did not reveal the root cause of lags in patient care and long hours in a waiting room. In fact, he found that this kind of study – throughput metrics, door to doctor, patient length of stay, staffing analysis, demand capacity, etc. – historically undertaken to solve this hemorrhage of patients and money, led to ‘paralysis by analysis.’ Even his Lean and Six Sigma approaches allowed for only short-term gains. Though hospitals across the nation were experiencing the same issue with no sustained results, hardwiring change was difficult. 

Dr. Dreyer’s frustration and a Divine nudging led him to what he knew was the only answer: Rather than analyze a broad overview of a ED and its systems, he needed to undertake an exhaustive analysis of each patient’s visit in the ED for a 24-hour period. What time did they come in? How long did they wait? Where were they sent? How long did they wait there? Why were they waiting? When were they seen by a doctor? What tests were ordered? How long before the tests were received? Where was the patient while waiting?

“To my knowledge,” says Dr. Dreyer, “this exhaustive, patient-by-patient analysis had never been done in a real hospital setting.” Hundreds of hours were spent in the analysis and the results were eye-opening: a real-time revelation of patient patterns, bottlenecks, overflows, and empty beds.

What would an ED look like if a charge nurse could see on one screen exactly what was going on in every room, every station, every point of patient contact in real time? Did that software exist? No, not in an ED setting. Developing software that displays real-time patient flow, resource utilization, care and “bottlenecks” became Dr. Dreyer’s mission.

The Dollars and Sense of the Emergency Department:

“The emergency room is the front door of every hospital in the nation.” – Dr. Dreyer

What few know (who live outside the world of a hospital) is the key to the need and profitability of CarePulse: The emergency room is the front door of every hospital in the nation. At least 65 to 75% of the patients occupying a hospital bed arrive through the ED. The image, policy, and financial impact of this “first impression” cannot be overstated.

While many laypersons view hospitals through the rightful lens of humanitarian purpose, in fact they are big business. Inefficient EDs = significant financial loss.

Long waits in the ED:

• Cause the patient to choose competitors
• Cause patients to leave without being seen (LWBS)
• Cause delays in diagnosis and treatment, leading to increased malpractice risk and decreased reputation
• Cause loss of real revenue – Insurers reimburse hospitals based on a “speed to care” method

Seen patients are profit. Approximately 75-90% of all ED patients are discharged after their visit. Profit to the hospital even for this short, one-time visit averages $240-$300. The remaining 10-25% ED patients are admitted; that patient earns the hospital $1200-$3200 profit. The annual lost cost for a hospital with 80,000 annual visits with 4% LWBS is a staggering $2.1M in lost profit, solely because of hidden process inefficiency and poor resource management.

Hospitals are ranked on websites and given “health grades.” ED delays cost the hospital in the all-important 4 Rs: Rankings, Reputation, Risk and Revenue. The cost of lost reputation and market share is significant. Examples of the significance of loss from LWBS and reduced payments from CMS (Center for Medicare Services including Medicare and Medicaid) due to lower grades include:

• Hospital A in Columbus, Ohio, with 65,000 annual ED visits - $2.02M annual profit loss, $5.5K daily loss
• Hospital B in Central Ohio, with 55,000 annual ED visits - $4.3M annual profit loss, $12K daily loss
• Hospital C in Florida, with 80,000 annual ED visits - $3.7M annual profit loss, $10.2K daily loss

Why are Emergency Departments inefficient?

The ED is a highly variable environment. In the blink of an eye, the ED can go from smooth sailing to chaos. Some sources of slowdowns are easily identified as when a trauma occurs or “the bus unloads.”  However, many are hidden and difficult to visualize, such as:

• Under or unutilized bed resources – Something as simple as a dirty sheet can cost a hospital thousands of dollars.
• Bed opportunities – Beds could be used for waiting patients if tasks were completed on the patient currently occupying the bed. Examples include: admitted patients transported to the floor, psychiatric patients transferred to open beds in psych unit, discharged patients who could be released. Delays in completing the tasks are not easily tracked or visualized.
• Testing delays – There is no monitoring or tracking system in place for the testing process. Things like samples not obtained, laboratory results delayed, technicians or equipment unavailable can go unnoticed, delaying the doctor's diagnosis and treatment, increasing morbidity and decreasing reimbursement.
• Surges – Unrecognized surges in volume or acuity can lead to over-utilized and unmanaged beds or resources.
• Management of admission flow – The ED admits a majority of their patients between 11am and 9pm. This coincides with the time that hospitalized patients are discharged. Hospitals do not have an overabundance of clean, staffed beds. To be profitable, the hospital must be over 85 to 90% occupied. Other hospital departments (surgical services, the cardiac catheterization lab, transfers, and direct admits) also need hospital beds during this time period. Coordinated and orchestrated bed placement is difficult.

Why can’t these bottlenecks be removed permanently with traditional methods?

Traditional process improvement efforts utilizing Lean and Six Sigma methodologies are successful in improving processes and patient flow. However, in healthcare, sustainable improvement is uncommon. The ED is a highly variable environment with many of the bottlenecks invisible.

Many hospitals have still not embraced Lean or Six Sigma thinking because ED staff turnover hinders sustainability of new standardized processes. Hardwiring behaviors is difficult.  

This hasn’t stopped hospitals from trying. Engineers and operations staff are brought on board. Marketing campaigns promise minimal wait times. Even with extensive effort (and dollars) old habits are hard to break and often these efforts are based on guesswork without gathering empirical data. 

“The reality across the nation is hospitals operate in an environment of responsibility-shifting, finger-pointing, and general inefficiency resulting in compromised patient care, lower staff morale, and leaner revenue.” – Dr. Dreyer