Steven Kelley's office is located next to the emergency department at Ellenville Regional Hospital.

"If I walk out and see someone sitting in the waiting room, I go over and ask what they are waiting for," says Kelley, CEO of the critical access hospital in upstate New York. "If the answer is anything other then they are waiting for a ride home, well, I want to know why."

For the most part, patients in Ellenville's ED are waiting for that ride. Over the course of the past few years, the hospital has cut the average ED length of stay from a mind-numbing three-plus hours to just 92 minutes, and that's in an ED where volume has grown from 7,000 visits in 2004 to 13,500.

"Everyone told me that our wait time was slightly better than average," Kelley says of that three-plus hours. "I think of average as mediocre. Being slightly better than mediocre? I don't think much of that."

Kelley exudes passion and confidence when he talks about the transformation at Ellenville. He can rattle off numerous federal, state and regional recognitions the hospital has received for quality improvement. His fight to "distinguish" Ellenville from the pack began in earnest five years ago when he came to the conclusion that the hospital had to elevate its game on the quality front if it was going to survive in an increasingly competitive environment.

One of Kelley's pivotal partners in this endeavor has been Robert Donaldson, president of the Ellenville medical staff and clinical director of emergency services. That Kelley would turn to a clinical leader to drive performance improvement isn't really that unique, but the fact that Donaldson is a nurse practitioner is. Think about it. How many NPs do you know who have been elected — twice — by physicians to be head of the medical staff? I'd venture to say you could count them on one hand and still have several fingers left over.

It hasn't always been this way. Similar to most rural hospitals, Ellenville had trouble recruiting top-flight physicians to serve on the staff. So, in the late 2000s, Kelley initiated an effort to let NPs practice independently in the ED. The medical staff approved the measure and, Kelley says, the hospital then was able to recruit top-flight NPs.

When an announcement went out in 2009 that there would be an election for president of the medical staff, Donaldson saw an opportunity.

"The medical staff bylaws said that NPs were equals, so I went to the vice president of physician affairs and said, ‘I'm an equal. Can I run?' The answer was 'Yes.'"

Donaldson won his first presidency in a run-off election. He was elected again in 2011. As for Kelley's plan to lure NPs to the area, that's working as well. The ED currently is staffed by three NPs and three PAs.

"I believe that NPs and PAs are the future of health care," says Donaldson, noting his obvious bias. "We can be a wonderful asset in this country with the change that's about to take place in health care."

Kelley agrees, but broadens it out. "The term ‘doctor' doesn't mean 'physician' anymore. We have doctors of NP, doctors of pharmacy, doctors of physical therapy, and so on. We are moving into a more integrated world."

For that integration to succeed, each cog in the machine must perform at the highest level, Kelley suggests. That's something Kelley and Donaldson discovered early in their effort to transform Ellenville.

"The ED is not a stand-alone department," Donaldson points out. "We depend on everyone else, so advances had to be made elsewhere."

The lab, for instance, was taking more than an hour to turn around results. When Kelley asked why, no one had a good response. They've cut the time to 21 minutes. They did the same thing in radiology. The goal is to find improvements at every step.

"There's nothing magic here; we just did basic stuff," Kelley says.