EMERGENCY%20DEPARTMENT%20OPERATIONAL%20IMPROVEMENTS

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EMERGENCY DEPARTMENTOPERATIONAL IMPROVEMENTS

• UHC
• January 27, 2010

Assaad J. Sayah, MD, FACEP Chief, Emergency
Medicine
Cambridge Health Alliance
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Overview of Cambridge Health AllianceProvider
Network

• Hospital
• 3 campuses with 24-hour Emergency Services
• The Cambridge Hospital
• Somerville Hospital (7/1/96)
• Whidden Memorial Hospital (7/1/01)
• Community-based Primary Care and Mental Health
  Services
• services at hospital campuses
• 18 neighborhood health centers, 4 school-based
  health centers
• CHAPO Cambridge Health Alliance Physicians
  Organization
• Employer and contractor for MD services
• Physician services organization provider
  enrollment, billing, claiming, malpractice
  coverage, HR support

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Overview of Cambridge Health AllianceNon
Provider Components

• Network Health- a statewide managed Medicaid
  health plan
• Medicaid products 92,785 covered lives
  Commonwealth Care products 68,280 covered lives
• Public Health
• Includes Cambridge Public Health Department and
  Institute for Community Health
• Work closely with public health departments in
  Everett and Somerville
• Alliance Foundation for Community Health
  (Philanthropy)
• Academics
• Teaching affiliations with
• Harvard Medical School
• Tufts Univ. School of Medicine
• Harvard School of Public Health Teaching
  Affiliate
• Training programs in social work, nursing, and
  occupational/physical therapy

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Regional Safety Net Provider

• Largest proportional provider of uncompensated
  care in the State. (33 of our service
  volume) AND (51 Medicaid 28 Medicare)
• Care for uninsured patients from over 257 MA
  communities
• Many patients travel to overcome access-to-care
  barriers (uninsured or under-insured,
  culturally and linguistically appropriate care)
• Leading state-wide acute hospital provider of
  inpatient psychiatry
• 10 of the statewide mental health discharges
• 33 of statewide mental health free care
  discharges.
• greater than 33 of our patients and 57 of our
  mental health patients come from outside our
  7-town primary service area

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Why Change ?

• Change in Healthcare environment
• Change in Healthcare reimbursement
• No Growth
• Poor patient satisfaction
• Inefficiencies

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Historical State
CH Registered ED Visits

• Annual visit volume has averaged 28.5k visits
  per year
• Through 5 mos, volume is down 2 from the PY

FY07 Projected represents the fist 5 months
annualized
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Essential Elements

• Leadership Team
• Constitution
• Alignment
• Commitment
• Communication
• Administration Support

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ED Vision for the Future
Current State
Capital Investment
Process
Staffing

• Patient Flow Project
• ED Flow
• Inpt. Discharges
• MD RN communication between ED and Inpt. Unit
• Triage/Registration
• Laboratory TAT
• Transfer Leakage

• ED Information System
• Tracking Board
• Electronic Medical Record
• ED Front End Redesign
• Wireless Bedside Registration

• MD Staffing/Productivity
• Nursing
• Clinical Support
• Administrative
• Registration

Future State (2-3 yrs)

• Best Practice Patient Satisfaction
• Door to Doc (30 mins / 90)
• Increased volume and capacity

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Staffing

• MD Staffing / productivity
• Culture
• Market analysis
• Comp plan
• Incentive
• Feedback

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2007 Hourly Compensation

• The goal is to close the compensation gap between
  CHA and competitors
• Recognizing the magnitude of the salary gap, the
  2007 proposal is to reduce less than half the gap
  between the CHA and the rest of the marketplace

Fully Loaded Hourly Compensation (Includes fringe
excludes malpractice)
Gap
Midpoint 176.02
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Two Tiered Compensation
Total Compensation
Salary Withhold Performance Bonus
Guaranteed Base Salary

• Total Compensation
• Market Competitive
• Experience based
• BC / BE
• Reviewed annually

• Salary Withhold
• Incorporates
• Productivity
• Quality
• Patient Satisfaction
• Citizenship

Salary Withhold
Guaranteed Base Salary
Total Compensation
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Monthly Physician Summary
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Quality PT Satisfaction

• Timely Chart Completion
• CHA-wide Initiatives (e.g. CAP Antibiotic Time)
• Chart Review for clinical compliance and
  appropriateness
• Pain Management
• PT Flow Metrics /Throughput times
• House Staff Evaluations

• Documentation of Conscious Sedation
• Incident Review
• Press Ganey by Physician
• PT Satisfaction (by measure of Complaints
  Compliments)
• Restraints
• Other

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Citizenship

• Staff Meeting Attendance
• Committee Participation Leadership
• Team Player (e.g. shift coverage flexibility)
• Administrative Duties Scholarly Activities
• Community Involvement

• Staff Compliments Concerns
• Compliance with administrative initiatives
• Other non-required activities which contribute to
  Emergency Medicine
• Other

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Staffing

• Nursing / Other
• Culture
• Support

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CH Nursing Support Staff Benchmarks
2005 ENA Emergency Department Benchmark Survey
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Patient Flow Project

• System Project Teams

Cambridge Health Alliance
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Patient Flow is a Hospital-Wide Concern

• Every hospital unit has a part to playthe ED
  cannot solve the flow problem alone.

Transport
Housekeeping
Case Mgmt.
Food Services
Radiology
Hospitalist
Admitting Registration
Laboratory
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Project Charter

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Patient Flow Project Goals

• Improve patient flow on all 3 campuses
• Do so in a timely, safe, effective, efficient,
  and patient-centered manner
• Implement best practices
• Utilize improvement methodologies, tools, and
  measures
• Utilize a multi-disciplinary, multi-campus single
  solution approach
• Engage hospital staff

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Structure

• Identify common issues across the system
• Consolidate various campus teams working on the
  same topic
• Multiple disciplines (MD,RN, Support Staff)
• Coordination among the teams
• Avoid redundant work
• Develop aggressive timelines for deliverables

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Focus is Across the Continuum
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Fundamental Mission of Teams
Team Mission
ED Patient Flow Minimize time patients spend in the ED through the application of best practices
Laboratory Turnaround Time Manage the ordering, collecting, testing, and verification of lab work through improved and standardized procedures
No Delay Nurse Report Transport admitted patients to inpatient unit within 30 minutes of ED nurse giving report
Physician Admitting Orders Expedite completion of admitting orders for admitted ED patients
Inpatient Discharges Decrease length of stay through effective discharge planning activities
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Project Methodology
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Recommendations

• Change ED flow
• Patient partner
• Mini Registration
• Triage patients in less than or equal to national
  average of 7 minutes
• ESI
• Bedside Registration
• Rapid assessment
• Maximization of bed utilization
• Culture change
• Admissions to virtual ED beds

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Recommendations

• Redefining roles of staff
• RNs and PAR IIs draw labs
• Charge Nurse Role
• RNs discharging patients
• Create MD Order Sets
• This has streamlined order entry
• Create RN Order Sets (MD Standing Orders)

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Recommendations

• IT
• EPIC / ASAP
• Dictation
• PACS
• MUSE
• System Integration
• PCP Initial notification
• Heads up from PCP and EMS
• Medical record access
• Access to ED workup
• Referral
• Standardization of
• P P, Guidelines
• ED documents
• Equipment
• Material

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Recommendations

• Process to improve quality of care
• Diagnostics
• Order sets
• Pneumatic Tubes in all EDs
• Labeling lab specimens with a barcode label
• Receiving the specimens in the lab using a
  barcode wand
• Throughput
• Early identification of admissions
• Maximize utilization of all inpatient capacity
• Early assignment of inpatient beds
• Early handoff to the admitting service
• Faxing nursing report on admitted patients
• Early transport to the floors
• Escalation process
• Back up
• Code Help

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ED Patient Partner

• ED Patient Access Representative
• Ambassador to patients in the waiting area
• Mini registration to facilitate patient flow
• Part of a response to deficiencies in Press Ganey
  patient satisfaction scores related to arrival
  and personal issues

Press Ganey Percentile Rank
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Rapid Assessment Overview

• The purpose of the unit is to facilitate rapid
  assessment and treatment at the point of arrival
  in the Emergency Department
• Combine Express Care and Triage to form a Rapid
  Assessment Unit (RA)
• Relocate Registration inside the ED (Promotes
  bedside registration)
• Combine nursing resources from Express Care and
  Triage offers the ability to care for multiple
  patients at once
• Move Physician Assistant to RA.
• The role of the PA is to rapidly assess and when
  applicable, treat and release the patient without
  entering the Acute ED.
• May also play a role in the initial assessment
  and ordering of diagnostics for acute patients.

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ED Transfers

• Transfer Form Developed
• Monitor External ED Transfers (100 case review
  by ED Site Chiefs)
• Understand Reasons for Transfer
• Bed Availability
• Specialty Availability
• Patient Preference
• PCP Preference
• Other
• Create a feedback tool to improve services and
  target opportunities to reduce system leakage

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Community Acquired Pneumonia
Core Measures In order to improve compliance
with Community Acquired Pneumonia core
measures, we developed a triage patient risk
scoring process for rapid identification and
management of CAP patients
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EPIC ASAP

• Emergency Department Information System

Cambridge Health Alliance
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EPIC ASAP Implementation

• The Phase 1 Implementation includes
• Electronic Triage
• Tracking Board
• Electronic Discharge Documentation /
  Prescriptions
• Go Live Dates
• TCH went live May, 2008
• SH, July 2008
• WH, November 2008

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Triage Discharge

• Triage
• Meditech interface of arrival information, chief
  complaints, and other patient data
• Nurses enter all triage documentation into ASAP
  which makes it available to the entire treatment
  team
• Discharge Documentation
• Diagnosis and Disposition
• Prescriptions
• Discharge Instructions

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Tracking Board

• Enables the ED to track and record all patient
  activities throughout their ED Visit beginning
  with registration through departure from the ED
• As the patient status changes (waiting for bed,
  waiting for provider, waiting for reevaluation,
  etc.) color codes are assigned to alert staff
• Results Reporting Lab Radiology
• Orders for POC testing, urine collection, EKG
  request, and safety measures are flagged on the
  tracking board and checked off as completed

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Tracking Board
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ED Manager View
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ED Dashboard
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Outcomes

• Results are overwhelming
• ED TAT reduced
• A 70 reduction in the number of patients
  leaving without being seen
• Patients have noticed a difference
• Press Ganey
• The reception area has remained empty during peak
  times
• This was the quickest emergency room visit I've
  ever had
• ED Staff feels like the ED is calmer less
  chaotic
• 100 of patients are registered at bedside
• Budget neutral
• Reallocated existing staff and space
• Zero up front capital costs

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ED Ambulance Diversion
Total Hours on Diversion

• Ambulance diversion is not good for our patients
• CHA has seen steady decreases in the number of
  hours on diversion
• Diversion has been eliminated at the Cambridge
  and Somerville campuses and has been
  significantly reduced at the Whidden

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ED Diversion Hours / of Time on Diversion
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ED Turnaround Time
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ED Press Ganey Patient Satisfaction Overall Mean
Score
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ED Left Without Being Seen Rate ()
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Historical Volume Trends

• Annual visit volume has averaged 28.5k visits
  per year
• Through 5 mos, volume is down 2 from the PY

CH Registered ED Visits
FY07 Projected represents the fist 5 months
annualized
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ED Visits Admissions
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Average ED Sensitive Quality Core Measures
Indicator Rates

• AMI ( ASA on arrival, B Blocker on arrival)
• CAP (Abx within 4 hours, BC prior to Abx)

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Challenges

• Sustain improvements
• Keep the staff engaged
• Continue to improve the system
• Output output output.

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Questions
Cambridge Health Alliance