Benchmarking shows quality efforts pay off for teaching hospitals' EDs
Benchmarking shows quality efforts pay off for teaching hospitals’ EDs
A groundbreaking study reinforces internal quality programs
A group of academic medical centers has compared notes on their internal quality management savvy in a groundbreaking benchmarking study of efficiency in the emergency department (ED). What they found was that automation and CQI techniques invariably produced the best practices.
Pressures from managed care organizations, Medicare, and Medicaid programs for more efficiency have forced teaching hospitals usually focused on their education goals to give a high priority to operational and clinical improvements, according to the University HealthSystem Consortium, (UHC) a nonprofit group representing university hospitals in Oak Brook, IL.
In 1995, UHC launched a year-long study called the Emergency Department Benchmarking Project. Earlier this year, it quietly shared with members the results of the 52-hospital study. For many UHC providers, the experience was an eye-opener.
"We learned where we came up short but surprised ourselves by how well we were doing certain things," observes Catherine Hamilton, RN, MPH, a clinical coordinator at the University of Cincinnati Hospital. The hospital was identified in the study as a "best performer" in several categories, including lab turnaround time.
The Cincinnati department’s response time on turning around complete blood counts clocked in at 36 minutes compared with 41 minutes for the study average. The Cincinnati ED also came in under 30 minutes for radiology cycle time compared with a study average of 35 minutes.
Cincinnati’s good showing stemmed from a large continuous quality improvement (CQI) initiative the hospital had implemented in late 1992. In the end, the initiative contributed significantly to cutting the department’s average length of stay for patients by 25% to 3.3 hours in 1995 from 4.4 hours in 1993.
You have to start somewhere
But how valid are such benchmarks when hospital EDs are fluid, unpredictable, and represent diverse patient settings?
"It is extremely difficult to draw conclusions. Nevertheless, EDs are struggling to find ways to differentiate themselves in order to remain viable" to payers, observes Richard L. Stennes, MD, president of Associated Emergency Physicians Medical Group, a San Diego, CA-based organization that provides hospitals with emergency physicians.
For academic centers, especially, two crucial factors contribute to achieving what Stennes terms "sustainable competitive advantage" in emergency medicine time and patient satisfaction.
"We have got to find ways to move patients through the ED in less time. Not only is it efficient to do so, it represents a key indicator of customer satisfaction," Stennes says.
Teaching hospitals are especially susceptible to long waits and inefficiency due to their emphasis on training and extremely large patient volumes, says Hamilton. The UHC project cited the following reasons for looking at emergency medicine:
• Managed care organizations are increasingly denying payments to all hospitals, citing inappropriate services delivered to nonemergency cases. Nearly half of ED patients can be seen in less expensive settings, according the national surveys.
• EDs have become the primary gateway for hospital admissions. An average of 34% of all UHC-member hospital admissions come through the ED. At Seattle-based Harborview Medical Center, for example, 70% of all admissions come through the ED.
• And operationally, teaching hospitals vary widely in the performance of their emergency units when compared to each other.
Project focused on problem areas
The UHC project surveyed member hospitals in six key areas: triage, registration, patient evaluation, ancillary services, admitting, and patient satisfaction.
Each of three randomly chosen hospitals interviewed by QI/TQM University of Cincinnati, Stanford (CA) Health Center, and Harborview Medical Center in Seattle credited its performance to the same factor: Management’s holistic approach to optimizing performance through quality efforts reduces time delays and boosts overall productivity. Here’s how the three hospitals did it:
After struggling for years with overcrowding and long waits in the ED, the University of Cincinnati Hospital embarked on a improvement plan to drastically redesign the entire patient-flow process from triage to disposition.
"We essentially combined certain steps in the traditional emergency department flow chart so that certain services were occurring concurrently rather than in linear fashion," Hamilton says. One major innovation occurred in admitting and patient evaluation.
Traditionally, the department wasted from one to three hours waiting for the inpatient physician to arrive, evaluate the patient, and notify admitting to locate an available bed in a probable admission.
The ED simplified the process by concurrently alerting the admitting department of a probable admission during the evaluation. The change trimmed at least one hour of waiting time for both patients and providers and has helped reduce overcrowding by moving more seriously ill patients out of the ED suites.
Crucial to the new system has been a probable admissions form, which the attending physician fills out and sends to admitting to initiate a bed allocation. If the patient ultimately isn’t admitted, the process reverts to a routine home discharge, Hamilton says. (For a copy of the form, see p. 88.)
Another innovation, which grew out of the CQI initiative, created nurse-physician teams that work together in moving less seriously ill patients from minor trauma through disposition, regardless of where in the department the patient ultimately goes, Hamilton says.
Rather than seeing patients randomly in sequence, which is the common practice in EDs, the team approach begins in triage and makes the single nurse-physician pairing responsible for the entire spectrum of the patient’s services. The system is enabled by computerized patient records and cellular phones that help make clinicians more mobile.
The automation and team approach moves patients through the system faster and distributes resources more efficiently, Hamilton says. The hospital sees some 65,000 ED visits annually. Some 40% are seen in minor trauma. Sixty percent of admissions come through the ED.
Combined with the shortened ancillary service turnaround, the team approach and efficiencies in admission helped Cincinnati Hospital achieve a 0.8 performance rating in each operating area compared with other hospitals in the study. (A 1.0 measure denotes "best in a class.") Of five other unidentified but presumably similar hospitals ranked by comparison in the benchmarking project, only one achieved equivalent scores in those areas.
Close is not always faster
Eliminating delays also played a key role in helping Stanford Health Services’ emergency staff achieve high ratings in the benchmark study. Spurred by a need to revamp patient flow, early in 1992, the hospital formed a quality council for the ED and a process improvement team to implement innovations.
High on the list of objectives was improving the average response time in the crucial ancillary service turnaround. With a small unit lab in the ED, the system was designed to save time, but it was actually doing the reverse.
"We discovered that our departmental lab was actually operating less efficiently than if we had sent the specimens to the hospital’s central lab," says Linda J. Bracken, RN, Stanford’s ED nurse manager. Understaffing at the unit lab was the primary reason for the lengthy delays in turnaround, Bracken says.
The delays varied with patient traffic but often exceeded an hour or more during peak hours. Annually, Stanford’s ED logs in some 36,336 visits of which 15% are level one trauma cases. Nearly, 25% of patients admitted to the hospital come from the ED.
Stanford eliminated the unit lab, and the department began sending specimens to the central lab for analysis. In all instances, the goal was to keep the turnaround at under an hour, says Bracken.
But surprisingly, the department beat its own expected time in the benchmark study. According to results, the turnaround for lab, chest X-ray, and consultation were 37%, 58%, and 17% below the study average, respectively. (For a comparison of actual times in each category, see bar graphs, p. 87.)
Twenty-four hour staffing in an on-site radiology room and a rigid adherence to a policy of answering pagers in 10 minutes and getting to the ED in 30 minutes helped achieve results in X-rays and consultation.
But the measurement that stood out was the time-to-disposition factor in complex cases involving chest pain and shortness of breath, which the study cited.
Patients with these presenting complaints are a potential liability in the ED because their final diagnoses can run the gamut from simple indigestion to serious myocardial infarction (MI), according to Robert L. Norris, MD, FACEP, Stanford’s acting chief of the division of emergency medicine.
"Fortunately, we have an aggressive, proactive cardiovascular [medical] group that helped us speed up the treatment process once we knew the actual diagnosis," Norris says. According to a plan initially worked out among the ED, cardiology, and the process improvement management team, patients with a diagnosed MI are sent directly to the catheter lab and seen by a resident or attending physician.
As a result, Stanford’s protocol came in well under the study average: 70 minutes to disposition compared with 160 minutes in the study for presenting chest pain and 80 minutes compared with 180 minutes for shortness of breath. Overall admission time for all cases in the ED averaged 80 minutes compared with 125 minutes in the study. (See Time to Dispositions graph, p. 87.)
With 76,000 patient visits per year, Harborview Medical Center operates a busy ED and level one trauma center that serves a four-state region of Washington, Alaska, Montana, and Idaho. Seven out of every 10 inpatients are admitted through the ED, one of the highest admissions ratios of the hospitals in the UHC project.
Even so, the hospital regards the ED as a low-tech, low-maintenance department, according to Christine Martin, RN, director of emergency services. "We have the necessary life-sustaining equipment, but we don’t invest in the latest bells and whistles, which keeps down prices for our patients," Martin says.
Because of the tight rein on capital investments, the hospital has had to carefully manage resources, which helped put the facility ahead of others in the benchmarking project’s categories of time-to-disposition and ancillary turnaround.
But the hospital also received above-average scores in three key financial benchmarks: hours worked, nonphysician dollars paid, and supply costs per adjusted visit. Martin would not share specific dollar amounts, but Harborview achieved ratings within 0.9 in each category with 1.0 being best.
Bundling stanched huge losses
At one time, "charges were not getting on the bill because residents were not using the conventional pricing stickers on documents. We were losing thousands of dollars in billable revenue," Martin says.
The solution, according to Martin, was price bundling and the use of standardized trauma kits, which are flat priced and easy to bill. These two innovations alone have helped ensure higher reimbursements, which has led to lower resource costs.
To prevent patient logjams and enable nurses to see more patients, in the early 1990s the hospital implemented a 15-minute turnaround policy on bed availability. In effect, "every floor of the hospital knows it cannot refuse to take a patient," Martin says.
The policy sparks a chain reaction in which every effort is made hospitalwide to maximize bed capacity, including assessing the feasibility of moving an ICU patient to an intermediate bed to open up bed space when clinically permissible.
In most cases, average patient waiting time to disposition ranges between 3.5 and 4.0 hours, which has worsened as the hospital has expanded the ED and increased patient capacity. "But management has worked hard to cut the waiting time for patients, and for us, at least, it’s an ongoing process," Martin says.
[For general information regarding the University HealthSystem Consortium (UHC) benchmark projects, contact:
• Danielle Carrier or Emmett Goldberg, University HealthSystem Consortium, 2001 Spring Road, Suite 700, Oak Brook, IL 60521-1890. Telephone: (630) 954-1700. Fax: (630) 954-5886. Web site: www.uhc.edu.
For more information on hospital emergency department benchmarking, contact:
• Catherine Hamilton, RN, MPH, Clinical Coordinator, Center for Emergency Care, University of Cincinnati Hospital, 231 Bethesda Ave., Cincinnati, OH 45267-0769. Telephone: (513) 558-5281. Fax: (513) 558-5791. E-mail: [email protected].
• Robert L. Norris, MD, FACEP, Acting Chief, Division of Emergency Medicine or Linda J. Bracken, RN, Nurse Manager of the Emergency Department, Stanford Health Services, 300 Pasteur Dr., Room H1261, Stanford, CA 94305-5239. Telephone: (415) 725-5069. Fax: (415) 725-6917.
• Richard L. Stennes, MD, FACEP, President, or Diana S. Contino, RN, MBA, Executive Vice President, Associated Emergency Physicians Medical Group, 480 Camino del Rio South, Suite 121, San Diego, CA 92108. Telephone: (619) 299-4770. Fax: (619) 299-8153. E-mail: [email protected].]
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