Analysis of Emergency Department Performance and HCAHPS Data

This report assesses the performance of an emergency department by analyzing HCAHPS data, comparing it to national and state averages. The evaluation focuses on key metrics such as patient wait times before being checked, admitted, and discharged, revealing areas where the department excels and lags. The report applies Kotter's model of change to recommend improvements, emphasizing the need for a sense of urgency, a guiding coalition, clear vision, and removal of barriers to enhance patient care. Specific recommendations include faster patient treatment, improved decision-making, and streamlined discharge processes to improve overall efficiency and patient satisfaction. The report concludes by underscoring the importance of continuous evaluation and adaptation to maintain high-quality emergency services.

Running head: EVALUATION OF EMERGENCY DEPARTMENT
EVALUATION OF EMERGENCY DEPARTMENT
Name of the Student
Name of the Author
Author Note

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Executive Summary
Hospital Consumer Assessment of Healthcare Providers and Systems or HCAHPS is an
instrument for collecting information from patients about their experience related to hospital care
and management. Bad experiences of patients in emergency departments involve the long
waiting time to be admitted, to get treated and also the poor decision making skills of the
healthcare professionals. Moreover, it also involves long waiting times to get discharged.
Kotter’s model of change generally provides the guidelines on how an organization should
organize and plan their approaches, carry out prompt decision-making and bring about effective
changes to ensure future improvements.

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Table of Contents
Introduction......................................................................................................................................3
HCAHPS Survey and Emergency standards...................................................................................3
Analysis of HCAHPS Data..............................................................................................................4
Recommendations............................................................................................................................6
Conclusion.......................................................................................................................................6
Reference List..................................................................................................................................8

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Introduction
Dr. John Kotter designed Kotter’s model of change. By following the guidelines or steps
laid down by Kotter, various organizations can prevent failures and can adapt new changes that
can increase their success rates and outcomes. His 8 step model can help organizations can bring
about changes that will ultimately help them to succeed (Appelbaum et al., 2012).
The 8 steps of Kotter’s change model include: creating a sense of urgency, creating a
guiding coalition, developing changes in vision, communicating the vision for acceptance,
empowering broad actions and removing barriers, generating visible and unambiguous success,
not letting up that is consolidating the gains and creating more change and establishing new
approaches in the change process (McDeavitt et al., 2012). The healthcare facilities are generally
associated with the presence of medical errors, which can be easily prevented. By adapting
changes along with the utilization of Kotter’s model of change, healthcare facilities can bring
about changes and implement their changes to prevent errors in the future (Cooke, 2016).
This report analyzes the HCAHPS data of the emergency department of a medical setting
in comparison to national standards and provides recommendations to improve the performance
of the emergency department.
HCAHPS Survey and Emergency standards
Hospital Consumer Assessment of Healthcare Providers and Systems or HCAHPS is an
instrument for collecting information from patients about their experience related to hospital care
and management (Manary et al., 2013). The standards set for emergency departments of
hospitals include: code, urgent, non-urgent, critical, ambulatory and disabled. There is

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significance attached to waiting time of patients. Patients with illnesses or injuries that require
urgent interventions, if kept waiting results in severe damage that can sometimes be life
threatening. The factors that determine the waiting time in emergency departments are: ratio of
nurse or doctor to patient, turnaround times in laboratories and X-rays and patient stay length
(French et al., 2014).
Many emergency rooms in urban areas are overcrowded. This occurs because the
emergency rooms are too small. On the other hand, the number of attending doctors and nurses
are too small compared to the large number of patients. Moreover, overcrowding also creates
lack of beds for patients who require emergency care (Sun et al., 2013). This increases the
average patient waiting time, which may result in serious consequences. On the other hand, the
doctors or the nurses are not able to provide sufficient care to each patient. Some of the factors
like long waiting hours for getting a report of a laboratory test, insufficient numbers of staffs and
lack of prompt action of hospital authorities can easily be rectified. Moreover, after diagnosis,
patients have to wait for a long time for transport or a bed. This in turn creates a chain event that
eventually increases the waiting times of future patients. Other problems include misplaced
reports which arise as a result of proper management and insufficient staffing.
Analysis of HCAHPS Data
On analyzing the Emergency department HCAHPS Data, it can be said that in some case,
the HCAHPS data is better than the national or standard data, however, in some cases it lags
behind compared to the national or state averages. Like, in the case of average time patients with
broken bones had to wait in the emergency department before getting checked and getting proper
medication was 47 minutes, which is far better than the national average but 1 minute less than

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the state average. Moreover, average time the patients had to spend in the emergency department
before being checked by a healthcare professional was 15 minutes, which is far better than both
the National and State average. However, in the rest of the cases, the HCAHPS data was lagging
behind when compared to the National and State averages. These include, average time the
patients had to spend in the emergency department before getting admitted was 246 minutes,
which is way behind compared to the national and state averages, which is 200 and 218 minute,
respectively. The average time the patients had to stay in the emergency department and wait for
being admitted after being checked by a doctor was 65 minutes, which is also higher compared
to the low amounts of time observed in the case of national and state averages , which were 48
and 60 minutes, respectively. Lastly, the average time the patients had to wait in the emergency
department before being discharged was 140 minutes, which is way higher compared to the
national and state averages of 116 minutes.
According to Kotter’s model, a sense of urgency is required in order to carry out effective
decisions and subsequent actions. A group of people is needed to carry out an emergency task in
a joint manner. No one person can carry out proper decision making, communicating to a large
number of people, managing and leading changes and bringing about new interventions, single-
handedly. The qualities of a highly effective team includes position power, credibility, expertise
and leadership (Kallas, 2014). It is very essential to develop changes in the existing vision in
order to bring about improvements in service. A clear vision helps in motivating people, helps in
coordinating actions and simplifies the decision making process. Moreover, it is also necessary
to make the people who are working to understand the vision and accept it, so that it can be a
joint effort in carrying out the change. It is also necessary to remove the barriers that prevent the
generation of proper services and to motivate the people through leadership and proper decision

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making so that they give their best. Short term successes should be acknowledged and teams
should be praised for their hard work in order to motivate them. However, short term gains
should not slow down the process of change and should bring about more changes that would
bring about further improvements in the future. It is also necessary to standardize the new
approaches and maintain an attitude of accepting changes in the future (Kash et al., 2014). Thus,
the emergency department described here should adapt to these changes in order to provide
effective and efficient services to the patients.
Recommendations
The emergency department needs to bring about changes regarding immediate patient
treatment and consultation. Patients with broken bones suffer from great pain and can give rise to
severe consequences if not immediately looked after. The emergency department needs to take a
serious and effective action to give relief to the patients and tend to their wounds. Moreover,
there are critical care patients who may need to be admitted to the intensive care unit. It is the
duty of the emergency department staff to organize and plan their action in order to admit such
patients and bring about necessary interventions. Moreover, it is also necessary for the doctor to
make quick decisions, so that the patient can be treated in a timely manner. Moreover, it is also
necessary that the patients when being discharged after being operated is not kept waiting, as it
affects the health of the patient. Thus, effective leadership skills and efficient and fast decision
making is needed to ensure high quality services to the patients.
Conclusion
Emergency departments in hospitals are places where individuals come who need
immediate medical care. Proper decision making, expertise and planning can help to save the

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lives of the patient or prevent the occurrence of severe consequences. Thus, it can be concluded
that emergency departments should analyze their skills and bring about effective changes in the
future for bringing about improvements.

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Reference List
Appelbaum, S. H., Habashy, S., Malo, J. L., & Shafiq, H. (2012). Back to the future: revisiting
Kotter's 1996 change model. Journal of Management Development, 31(8), 764-782.
Cooke, M. (2016). TeamSTEPPS for health care risk managers: Improving teamwork and
communication. Journal of Healthcare Risk Management, 36(1), 35-45.
French, S., Lindo, J. L., Jean, E. W. W., & Williams-Johnson, J. (2014). Doctor at triage–Effect
on waiting time and patient satisfaction in a Jamaican hospital. International emergency
nursing, 22(3), 123-126.
Kallas, K. D. (2014). Profile of an excellent nurse manager: identifying and developing health
care team leaders. Nursing administration quarterly, 38(3), 261-268.
Kash, B. A., Spaulding, A., Johnson, C. E., & Gamm, L. (2014). Success factors for strategic
change initiatives: A qualitative study of healthcare administrators' perspectives. Journal
of Healthcare Management, 59(1), 65-82.
Manary, M. P., Boulding, W., Staelin, R., & Glickman, S. W. (2013). The patient experience and
health outcomes. New England Journal of Medicine, 368(3), 201-203.
McDeavitt, J. T., Wade, K. E., Smith, R. E., & Worsowicz, G. (2012). Understanding change
management. PM&R, 4(2), 141-143.
Sun, B. C., Hsia, R. Y., Weiss, R. E., Zingmond, D., Liang, L. J., Han, W., & Asch, S. M.
(2013). Effect of emergency department crowding on outcomes of admitted
patients. Annals of emergency medicine, 61(6), 605-611.