PS: Our work actually began in March 2015. We have a very large academic medical center with 96,000 discharges a year and a little over 300,000 ED patients. We were in the busiest quarter of the year and were falling behind our admission and discharge targets in the first two months. We were contemplating all kinds of actions, and chose to take on ED crowding.

It was really unbelievable in the middle of March, the winter flu season. The emergency department was packed, and yet all of these admitted patients were being boarded because we were not looking at ED crowding as a system-wide issue. One of the less popular but most important changes we made was that we insisted that each of our key directors join me and come in on the weekends. We worked consecutively for about six months, every Saturday and Sunday, so that we could get a much better understanding of some of the rate-limiting steps to safely discharge patients. It was painfully apparent that things that should have been happening on Saturday and Sunday simply were not.

An example was that you couldn’t get an echocardiograph done on a Saturday or a Sunday. It turned out it was only a matter of talking to the leadership in cardiology and saying, “Guys, we have to find a way to do echos seven days a week, especially if it’s going to help our clinical teams reach disposition decisions.” Today, we have access to echos seven days a week.

We also realigned the schedules of our physical therapists because we didn’t have rehabilitation services on Saturdays and Sundays, a major barrier to discharges. We asked them to schedule over a seven-day period instead of a five-day period. We did the same thing with social services. We identified the five biggest nursing homes that we do business with and clearly communicated to them that if they valued the Montefiore business, they needed to figure out a way to have intake coordinators available to us on weekends. It’s amazing. Once you put that kind of pressure and leverage on them, everything changes.

PV: How hard was it to get people to come in on weekends?

PS: I think initially there was a tremendous amount of resistance at the leadership level to coming in on Saturdays and Sundays. It was a matter of working seven days a week for six months to really better understand some of the struggles that our clinical teams were having on weekends. The skeptics started to see the change by going downstairs and seeing the impact that it was having. Now on Monday morning, our biggest day of the week, there are only two or three patients waiting for beds.