Quality of care and emergency department throughput during the COVID-19 pandemic in a community health system

The COVID-19 pandemic has caused significant challenges for individuals and healthcare facilities, particularly hospitals. Despite these difficulties, hospitals have remained committed to maintaining and improving the quality of care and patient satisfaction. The ongoing global health crisis has highlighted the critical concern of ensuring service quality during the pandemic, emphasizing the need for comprehensive measures to safeguard the well-being of individuals seeking medical care.

However, the COVID-19 pandemic severely impacted patient decision-making regarding healthcare access. Fear of virus exposure in healthcare settings created widespread reluctance, leading many individuals to postpone or avoid essential medical attention.^[1] This resulted in delayed diagnoses and treatments, potentially worsening health conditions and negatively impacting patient outcomes.^[2] As healthcare providers engage with these complex issues, the healthcare system’s quest for solutions and strategies has become imperative. To ensure the quality of care and emergency department (ED) processing time during these unprecedented circumstances, it is important to thoroughly understand these challenges and continuously pursue solutions.

2.1Setting

AHMC Health System (AHMC) is a healthcare system of 10 community hospitals across California, USA. With 2,200 beds, a network of 6,000 affiliated physicians, and over 10,000 employees (as of 2024^[3]), AHMC Health System prioritizes delivering high-quality care and ensuring patient satisfaction, earning numerous regional, national, and international accolades. At the beginning of the pandemic, to minimize the impact of care on patients, AHMC implemented a three-layer strategic plan, which included the “Pandemic Response,” “ED Throughput,” and “Quality Excellence” (see Figure 1). This three-layer strategic plan aimed at effectively managing the challenging circumstances and meeting the demands of the situation, but also prioritized enhancing healthcare capacity, strengthening staffing, ensuring efficient and safe treatment, and improving hospital quality using Lean Six Sigma and the Six-Dimensional Approach.^[4] These measures demonstrated AHMC’s commitment to effectively responding to the pandemic and maintaining high-quality, patient safety and satisfaction in the ED.

Figure 1.

Three-layer strategic plan for promoting patient safety, satisfaction, quality of care, and ED efficiency during the COVID-19 pandemic at AHMC Health System

2.2Layer 1: Pandemic response

2.3Layer 2: ED throughput

2.4Layer 3: Quality excellence

Throughout the four-year battle against COVID-19, AHMC has exemplified resilience and adaptability in its approach to hospital administration. The “Pandemic Response” was highlighted by noteworthy achievements, including cross-training staff, ensuring adequate supplies, and preparing for a surge in severe COVID-19 patients.^[10] For example, more than 150,000 patients were tested, with 22,287 positive cases identified across AHMC’s ten hospitals. Additionally, AHMC expanded its ventilator inventory by 50% and sourced over 300,000 masks and essential PPE through collaborations with the Los Angeles County Department of Public Health (LACDPH), healthcare foundations, local communities, and international partners. AHMC led in providing outpatient care with new antiviral treatments and monoclonal antibody infusion service in the ED, reducing COVID-19 hospitalization rates from 10% at the beginning to 3% in 2023. Furthermore, AHMC maintained average nosocomial infection rates under 4% and achieved an employee vaccination rate above 90% in 2023. Lastly, the organization also conducted a comprehensive COVID-19 health outcome study and published it in a renowned international journal,^[11] providing valuable insights by analyzing disparities between Asian and non-Asian patients following hospitalization. This initiative aligned with other research efforts to understand disparities in COVID-19 outcomes among diverse populations. Additionally, in 2021, AHMC facilitated organizational growth and expanded its service areas to provide more affordable and accessible community care. This was achieved through the acquisition of two hospitals in Northern California, with 116 and 357 beds respectively, thereby enhancing community healthcare access in the region.^[12]

Our commitment extended to the second layer, “ED Throughput,” and we successfully achieved most of the ED throughput objectives. As shown in Table 1, the door-to-doc time decreased to a mere 13.2 minutes, surpassing the target by nearly half. Furthermore, we achieved an efficient median ancillary TAT of 40 minutes and an ED LOS of 146 minutes. Moreover, our LWBS rate decreased to less than 1%. Alongside these improvements, our ED CAHPS score reached 60.46%. These outcomes demonstrate our concerted efforts to reduce wait times, enhance patient safety and satisfaction, and ensure the delivery of effective and compassionate care.

The third layer, “Quality Excellence,” emphasized our aim of achieving and sustaining high-quality healthcare services. In the face of these challenges, AHMC’s continued efforts towards quality and patient satisfaction have improved its CMS Quality Star Rating, steadily climbing from 2.43 to 3.22 between 2020 and 2023. During this period, we saw an expansion in the number of our hospitals and achieved average Yelp review scores that surpassed those of neighboring hospitals. These accomplishments were particularly noteworthy considering the backdrop of the pandemic and its pervasive impacts on healthcare institutions. These outcomes signified AHMC’s capacity to navigate and overcome pandemic-induced disruptions while steadfastly focusing on providing high-quality healthcare services to our communities.

The pandemic has significantly impacted people’s lives and presented substantial challenges to healthcare facilities. In response, AHMC has focused on maintaining high patient safety, satisfaction, and quality of care standards. This included implementing the three-layer strategic plan that has helped us achieve our goals. The three-layer strategic plan, adaptability, and proactive approach provided valuable insights for healthcare institutions looking to maintain high standards during the pandemic and beyond.^[13] It may offer insights as a reference for other hospitals to consider. Despite the hospital achieving commendable outcomes, there exists room for further enhancement. Throughout the pandemic and post-COVID era, we observed periodic fluctuations in quality control metrics.^[14] Identifying the main reasons for these differences was important to improve this situation. A key element of this process was the effort invested in maintaining consistent standards of care and operational efficiency. Proactive steps such as regularly calibrating medical equipment, ensuring adequate staffing, and consistently adhering to hygiene and safety protocols were fundamental to a seamless healthcare delivery system.^[15] By prioritizing routine checks and fostering a culture of continuous improvement, we aimed to stabilize and enhance the patient experience while mitigating risks. In the aftermath of the pandemic, numerous challenges^[16] have emerged, necessitating immediate and strategic attention.

As depicted in Table 1, our key areas of concentration for improvement included ED LOS, CMS Quality Star Ratings, the Leapfrog Hospital Safety Grade, and Yelp review scores. Although we achieved our benchmark LOS goal in 2023, examining the previous year’s figures reveals room for additional improvement. In the face of this challenge, incorporating strategic initiatives such as streamlining procedural workflows, strategically allocating staffing resources, and implementing effective triage paradigms could hold promising potential. By aligning these measures with our goals, the efficiency of the ED performance could be improved, resulting in great reductions in LOS metrics. Additionally, the efficient utilization of point-of-care testing has decreased patients’ ED waiting times. Enhancing patient flow and alleviating departmental crowding can be achieved by introducing novel working practices and incorporating advanced technologies like point-of-care testing in the ED.^[17,18]

During the COVID-19 period, numerous families have endured the pain of having their loved ones contract the virus, experience diminished quality of life or even succumb to it.^[19] The resulting anger and frustration can be vented through negative ratings on the application platforms, impacting both the CMS Quality Star Rating and social media scores.

Focusing on maintaining and improving the quality of care and ED efficiency, this study elaborates on AHMC’s three-layer strategic plan, which includes “Pandemic Response,” “ED Throughput,” and “Quality Excellence.” Despite facing challenges such as staff shortages, resource constraints, patient reluctance, employee adaptation, financial stress, and mental health issues, AHMC has demonstrated resilience and innovation in response to the constantly evolving COVID-19 pandemic.

AHMC’s progress includes an increase in ventilator inventory, collaborative procurement of PPE, and the implementation of updated treatments as they become available, such as Remdesivir and Paxlovid in the emergency department. Additionally, AHMC has maintained a high staff vaccination rate and a low rate of nosocomial infections. Regarding emergency department throughput, AHMC has excelled in metrics such as median door-to-doc time, Ancillary TAT, ED LOS, and LWBS rates, surpassing established goals. The patient-centered approach is also reflected in the overall ED CAHPS scores. The layer of “Quality Excellence” emphasizes AHMC’s commitment to achieving and maintaining high-quality healthcare services. The CMS star rating has improved, and the average Yelp review scores exceed that of neighboring hospitals, demonstrating its commitment to patient satisfaction throughout the community.

Despite these achievements, we have identified areas that require further improvement. We recognize the need for continuous progress in quality of care indicators, a more comprehensive focus on reducing ED LOS times, and substantial enhancements in CMS star ratings, Leapfrog patient safety grades, and Yelp review scores. AHMC acknowledges that sustained progress and a strategic focus on addressing the challenges posed by the pandemic are essential for stabilizing and elevating the patient experience.

COVID-19 represents a pivotal transition point in our lives, imposing substantial challenges that span the domains of public health, socio-economic stability, and global collaboration. These hardships have resonated across communities and nations, ushering in a period of reflection and necessitating adaptation. It is crucial not only to acknowledge these adversities, but also to learn from them. Academics, policymakers, and practitioners must examine the global response, identify gaps, and strategize for future crises. The narrative should shift towards constructive learning and proactive improvement, contributing to the development of more resilient public health systems and enhancing societal preparedness.

Furthermore, effective teamwork and collaborative sharing play pivotal roles in addressing the challenges posed by the pandemic. Cross-national and inter-organizational exchanges foster mutual understanding and cooperation, expediting the return of individuals to a harmonious everyday life.^[20] This interconnected approach facilitates the exchange of ideas, resources, and expertise, further enhancing the collective efforts to restore a sense of peace and stability within communities. Consequently, the pandemic highlights the importance of continuous improvement and collaboration, guiding academic discourse towards the development of resilient and transformative strategies.

Wen-Ta Chiu: Conceptualization, methodology, validation, writing, supervision; Wan-Yi Lin: Conceptualization, formal analysis, writing, visualization, project administration; Yu-Tien Lin: Conceptualization, writing, visualization, project administration; Chia-Hsing Yeh: Conceptualization, writing, visualization; Kaveh Aflakian, Pei-Chen Pan, Chien-Yu Liu, Han-Kuan Bai: Investigation, validation, writing; Stanley Toy, John Chon, Steve Giordano, Victor Lange, Suyen Wu, Jonathan Wu: Conceptualization, methodology, validation, supervision.

Informed patient consent was not required because no patient clinical or identity data was collected, and no patient interventions were completed during the course of study. Therefore ethical review board approval was not required and waived.

This work has no external financial support.

The authors declare that there is no conflicts of interest.

The Publication Ethics Committee of the Sciedu Press. The journal’s policies adhere to the Core Practices established by the Committee on Publication Ethics (COPE).

Not commissioned; externally double-blind peer reviewed.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

No additional data are available.