WINTER HAVEN -- Winter Haven Hospital officials didn't like what they were hearing about their emergency department.
Eight percent, roughly 1 in 12 patients, walked out before being treated in 2003.
Patients' satisfaction with the department was in the bottom quarter nationwide in spring 2006, according to a national database.
Patients said emergency department waits were unacceptable. And, they wanted more information from emergency department employees.
Everyone from the emergency department staff to the hospital administration and community board of trustees took a collective gulp.
Stung by the criticism, they embarked on a project in March 2007 to improve wait times and to make the department more efficient and caring.
"Wait time and clear answers to questions are the things we try to work on every day," said Jenny Blank, assistant vice president of emergency services. "We need to be sure people are updated through their stay on what's going on."
Reform centered on the emergency department, but it rapidly developed into a hospitalwide process of evaluation and changes.
"The hospital made the (emergency department) a priority," said Dr. Ron Berman, chairman of the Emergency Medicine Department and part of the University of Florida team of doctors who treat patients there.
"There were a lot of negative thoughts concerning the ER," he said. "The hospital took it on itself to improve that."
It's rare for hospital leaders to talk publicly about its faults.
The reason some at Winter Haven Hospital are eager to discuss what happened is that they're proud of the improvements made.
In October, a poster presentation by nurses on the improvement project won an award for "structural empowerment" at the American Nurses Credentialing Center National Magnet Conference. Judges credited the hospital for nurses' leadership role in working with hospital board members to examine the system and find solutions to problems.
"It was interdisciplinary and we really weren't afraid to try anything," Blank said. "You have to be really creative and innovative to look at what works."
Blank and others affiliated with the improvement project shared some of the hospital's current statistics at a presentation to hospital nurses in January.
Of 60,251 visits to the emergency department in 2010, the percentage leaving without being seen was just under 3 percent. That was 1,732 people, the first time that number had been below 2,000 since 1996.
For December 2010 alone, the percentage was just under 2 percent.
"It's a work in progress, but we think we've turned the corner," Berman said.
Significantly improving the emergency department proved impossible without an analysis of every department within the hospital.
"Before this started out ... I don't think everybody understood how we need each other to make things work," Berman said.
"We worked with our lab to get information faster. We've worked with our radiology department to get studies done faster. It goes down to housekeeping and getting the room clean faster."
Kenneth Silfies, 56, went to the emergency department the afternoon of Jan. 11 after an insect sting. He said he was surprised by how rapidly he was taken into a private enclosure in the department and treated. He had no complaints after the stay ended.
Not all patients are satisfied, however.
Dorinda Harris, at the hospital Aug. 2 with her father, Charles Green, said he dressed and left the treatment area of the ER when his requests for additional pain medication for severe chest pain weren't met. She has complained to the state regarding the behavior and attitude of a nurse.
Her father, 84, had a history of heart disease. He was taken to Winter Haven Hospital by ambulance from Lake Wales, for what emergency medical personnel said was a heart attack, she said. After leaving the hospital that night, she said, he went to Lake Wales Medical Center the next day.
From there, he was taken back to Winter Haven Hospital for a procedure in its cardiac catheterization lab, she said.
The hospital's risk manager, learning of the complaint, sent Harris a letter saying her information had been sent to the nursing administration staff and for physician peer review. She apologized "that we failed to meet expectations regarding the care rendered your father."
A customer service team of hospital trustees, emergency department nurses, management and employees from other departments that works on improving processes throughout the hospital.
"We certainly could not have made the changes we have unless there was help from every partner within the hospital," Blank said.
Some hospital board members and senior leaders did rounds in the emergency department, which she said let them see firsthand the issues that needed to be addressed. That helped the department get the resources it needed to make changes.
Beth Koon, a quality improvement manager deeply involved in the project, said the hospital still is working on improvements in emergency care.
"Are we where we want to be?" she asked. "No, but we're getting there."
The next steps on the agenda include a new rapid assessment area, enhanced discharge instructions and nurses steering doctors to see each patient again before the patients are discharged.
The hospital also will incorporate caring factors into job descriptions and performance evaluations, according to the poster summarizing the project to improve emergency department satisfaction.
These come from nationally known nursing expert Jean Watson's caring theory of 10 "caritas factors." Those include practice of loving kindness and sensitivity to self and others. Winter Haven Hospital nurses have been working with Watson and her theory for years.
Koon said the hospital used "small experiments of change" to see quickly which would work.
A committee with members from throughout the hospital still meets regularly, Blank said, adding that nurses and other emergency department employees make rounds on the hour or half hour.
"When we first started this ... we were looking at the big things first," Berman said. "Now we're working on things that save ourselves minutes."
One seemingly minor change -- getting a CT scan into the emergency department instead of having it down the hall -- saves 15 minutes on average for patients needing the scan.
The length of time for a patient to leave or be admitted typically was eight hours when he arrived about eight years ago, Berman said. Now it's in "the region of three hours to three and three-fourths hours."
Changes wouldn't have occurred without support from the trustees and hospital administration, he and Blank said.
"What I keep harping on to anyone who'll listen to me is this all comes from the top down," Berman said.
"From the board of our directors and our CEO, if it wasn't their desire, it wouldn't happen."