Maintaining high-performance is never easy in a busy ED, especially when it’s in a Level I trauma facility that treats a steady stream of high-acuity patients. However, data from the Emergency Department Benchmarking Alliance (EDBA), a nonprofit organization that collects and maintains a database on ED performance metrics, suggests that ProMedica Toledo Hospital in Toledo, OH, has been able to hit the mark on processing measures year after year.
“This ED has done a tremendous job over the years in processing patients very effectively in a small-sized ED,” observes James Augustine, MD, FACEP, the vice president of EDBA and director of clinical operations at US Acute Care Solutions. “Last year, the hospital’s ED improved their process even further, and now has the best performance in an ED with more than 100,000 patients annually that I have ever seen in our EDBA data.”
For instance, the hospital reports that the median door-to-bed time in its ED is 23 minutes, and the median bed-to-physician time is eight minutes. Further, the median length of stay for all ED patients stands at 121 minutes, and hospital administrators note that the ED’s leave-without-being-seen (LWBS) rate tends to hover around the 1% range, far below the national average.
What has the hospital done to achieve and sustain such performance metrics? There have been a number of concrete steps, and ED leaders note they are a data-driven group, with a firm commitment to providing staff with regular feedback on their collective and individual performance metrics. However, ED leaders also acknowledge that to get staff to buy in to performance initiatives, they have to fully understand the reasoning behind such efforts, and they must have both a game plan and the necessary resources to succeed.
Empower Nurses
Beth Estep, MSN, RN, CEN, director of the ED at ProMedica Toledo, credits much of the department’s improvement in processing times to an overhaul of the triage process.
“We all know our front door is critical to us,” she says. “The whole goal is to get patients to the provider as soon as we can.”
Consequently, the minute a patient arrives in the ED, emergency personnel engage with the individual to determine why he or she is there.
“We do have immediate bedding here, so if we have beds open, we do a quick registration just to get some quick information and numbers, and then we immediately get the patient back to a bed so that we can triage him or her in the back,” Estep notes. “We can get a whole heck of a lot of things going on in the back along with the most important thing: getting the provider in to see the patient for that medical screening exam.”
When the ED is operating at full capacity, and there are no open beds, staff members begin the triage process out front.
“We have preemptive guidelines that we work on so that we can be sure to initiate some of the testing that is within the scope of the nurses out front. This is done so that by the time the patient arrives in the back, we have some of the items completed for the providers,” Estep explains.
Specifically, the hospital follows guidelines established by the Ohio Board of Nursing, which empowers nurses to order certain labs, X-rays, ECGs, and urine tests, Estep observes.
“When the providers see the patients, they are not starting from step one,” she adds.
Provide Ongoing Feedback
Providers also are regularly apprised of their patient processing times, explains Brian Kaminski, DO, CPPS, medical director of the ED.
“We provide feedback on a lot of data points,” he observes. “We look at overall LOS [length of stay], bed-to-physician time, time to disposition, and disposition until removal through the system. We categorize these, and we really just rank and stack our physicians so that everybody gets the data on all the physicians sent to them.”
Physician leaders then focus on the physicians who work at both ends of the spectrum.
“If on one data point they are a standard deviation or more to the good, we will use them as an example, and sometimes pair them with some of our less productive or less efficient physicians so they can learn from the productive ones,” Kaminski notes. “At the same time, in a more private manner, we will coach, educate, and provide additional resources to those folks who are a standard deviation or more to the negative side.”
This steady stream of feedback has become part of the culture, Kaminski explains.
“This is an item of importance. We talk about it at every department meeting, so it is something that is always high on the radar,” he says.
Further, Kaminski notes that the ED physician group has hired an executive director with a business background to take charge of the data collection and feedback process.
“He has an MBA, and a big part of his role is helping deliver that data to our providers, and helping mentor the ones that are low on the productivity side to become better performers,” Kaminski explains.
Devise Optimally Sized Teams
From an operational standpoint, ED leaders look closely at volume curves so that staff schedules are in accordance with anticipated demand for a given period. Further, Kaminski credits the ED’s switch to a zone system in 2002 as a particularly effective method of boosting productivity.
“The staffing model [used to have] all the doctors just kind of floating around and just picking up the next patient,” he explains.
However, under the zone system, instead of physicians picking up the next available patient, staff members triage patients to a specific zone that operates almost like its own smaller ED within an ED, Kaminski explains.
“The physician doesn’t have direct control of the patients who are triaged to that area. That is done by the charge nurse,” he says.
Under the zone system, when a bed is open and available, the next patient goes to that zone, and ED leaders know which physician is responsible for the patient because he or she is responsible for the entire zone.
“Physicians can’t delay or wait to see if someone else will pick up the patient. He or she is theirs from the moment the patient goes into a room,” Kaminski explains. “It is not always easy to operate this way, but we think from an efficiency standpoint putting that flow process in the hands of the charge nurse, who has great visibility of the department, is where the decision point ought to be.”
With experience working in and witnessing the operations of large EDs, Kaminski notes that one of the strategies often utilized is to view the entire ED as one unit that operates as a big team, but that is not the method he favors.
“The approach we have taken is really centered more around the idea that once teams reach a certain size they tend to be more dysfunctional, so when we staffed and set up the model we are currently using ... we really wanted to create different teams of optimal sizes,” he explains. “We generally refer to two different zones, but depending on the time of day, we can actually have five different zones.”
For example, there is an express care area and a pediatric area that both operate independently, and then the main ED is divided between zone A and zone B, Kaminski explains.
“Then, when we reach a volume peak in mid-afternoon, we actually create an additional zone,” he says. “So during the peak hours of the day, we have five independent teams working within the larger ED, and during the lower volume parts of the day, we have two teams, so we flex and bend our staffing according to the volume, but with the idea that we want to have teams with a finite number of team members on each team so that everyone is performing to their maximum capability.”
Another strategy that helps with staffing: ED leaders try to hire and recruit people who have experience working in high-volume settings.
“If we have candidates coming in that have never done that before, it might not be the best environment for them,” Kaminski notes. “We tend to steer away from them and hire and recruit people who are more comfortable in a [higher-intensity] environment.”
Nurture Relationships
The ED has made relationship-building between physicians and nurses a priority, and this has paid dividends in improved communications and operational efficiency, Estep observes. The ED has reached these goals, in part, through the zone system and strategic scheduling.
“The physicians work a seven-days-on-seven-days-off type of concept, but when they are here and they are assigned to zone A or zone B, they are working with the same set of nurses, so they build relationships with them and dialogue with them,” Estep notes.
Further, when new nurses come on board, ED leaders make sure they are introduced to the physicians, and their pictures are posted so that everyone knows who is coming on board. Estep adds that the night supervisors play a key role in making sure that incoming nurses are well-integrated into the culture of the ED because this is where new staff generally first come on board.
“They are doing team-building exercises two or three times a week, and they include the physicians,” Estep says. “That really does help [the physicians and nurses] bond.”
Beyond efficiency improvements, ED leaders note they are particularly focused on matters of safety.
“We put every one of our employees through error-prevention training, which is giving them tools and techniques in high reliability,” Kaminski explains. “One of the fundamental core values in error prevention training is communicating clearly, and we give people communications techniques to use to not only communicate effectively, but also to recognize high-risk situations ... and how to escalate when something is important and there is a concern.”
Kaminski adds that while electronic medical records (EMR) are a wonderful tool, they have their limitations. This point was illustrated in Dallas during the Ebola scare in 2014 when a patient’s travel history, which should have been a red flag, was not effectively communicated from triage to the rest of the department.
“Not everybody reads every piece of information in the EMR as they are seeing and treating patients, so error-prevention techniques are designed in a way that our hope is that we would be able to see a situation like that,” he explains.
Learn From Others
While ED leaders are proud of the process improvements they have achieved, they still see plenty of opportunities for further gains.
“Our processes aren’t perfect. We still have significant frustration with some of the patients that we do board, and we would like to do that better,” Kaminiski admits.
Another target is the ED’s performance on patient satisfaction surveys. Those figures tend to be average, Kaminski admits.
“We’ve got to focus on the patient experience,” he says. “We’ve developed a mission statement, and we have developed a pledge that we are going to have all providers and employees sign. We have goals and metrics from the safety, quality, and satisfaction standpoint that we are going to track.”
Kaminski adds that ED leaders are in the process of recruiting champions and coaches to launch the initiative, with a target date for implementation in early 2017.
With all the recent mass-casualty events in mind, Estep is determined to engage the entire hospital in more drills to prepare for such events. That is the key recommendation she has gleaned from hospital administrators in areas that have recounted their experiences in managing mass-shooting incidents.
“It isn’t just about the ED drilling because you need help,” she says. “You need to be able to have everyone deployed.”
On any of these issues, the key to getting staff to go along with a new approach is to embrace it and model it yourself, Estep says.
“[Staff members] are an extension to us, and if they believe in what we do and they know that we are walking the walk ... they will go out there and do everything they can to man the department in any aspect of great care and great service,” she observes. “The key here is that it always starts with us.”
SOURCES
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Beth Estep, MSN, RN, CEN, Director of the ED, ProMedica Toledo Hospital, Toledo, OH. Email: [email protected].
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Brian Kaminski, DO, CPPS, Medical Director of the ED, ProMedica Toledo Hospital, Toledo, OH. Email: [email protected].
