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Emergency Department Quality Improvement Transforming the Delivery of Care

Overcrowding in the emergency department has been associated with increased inpatient mortality, increased length of stay, and increased costs for admitted patients. ED wait times and patients who leave without seeing a qualified medical provider are indicators of overcrowding. A data-driven system approach is needed to address these problems and redesign the delivery of emergency care.

This article explores common problems in emergency care and insights into embarking on a successful quality improvement journey to transform care delivery in the ED, including an exploration of the following topics:

A four-step approach to redesigning the delivery of emergency care.
Understanding ED performance.
Revising High-Impact Workflows.
Revising Staffing Patterns.
Setting Leadership Expectations.
Improving the Patient Experience.

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Emergency Department Quality Improvement Transforming the Delivery of Care

  1. 1. Emergency Department Quality Improvement: Transforming the Delivery of Care
  2. 2. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Transforming Emergency Care This report is based on a 2018 Healthcare Analytics Summit (HAS 18) presentation given by Linda Hummel, MS, BSN, RN, Vice President of Quality and Patient Safety at Mission Health System and Rick Lee, MSN, RN, CEN, NE-BC, Executive Director of Emergency Services at Mission Health System, entitled “Transforming Emergency Care with Analytics and Technologies.” Linda Hummel, RN, BSN, MS Vice President, Quality and Safety Mission Health System Rick Lee, RN, MSN, CEN, NE-BC Executive Director, Emergency Services Mission Health System
  3. 3. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. More than half of all U.S. hospitals report over- crowding in the Emergency Department (ED). One-third report an increase in ambulance diversion and 90 percent report they frequently operate at or over capacity. This risks the ability to effectively provide emergency care to those who need it and contributing to patient dissatisfaction. Transforming Emergency Care
  4. 4. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Overcrowded EDs cause problems for both hospital patients and staff, such as increased wait times, length of stay (LOS), medical errors, and mortality rates, as well as financial losses to hospitals. A data-driven systems approach can dramatically improve every aspect of emergency care, improving wait times and throughput, reducing left without being seen rates, and improving patient satisfaction. Transforming Emergency Care
  5. 5. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Crowding in the ED has become a widespread problem in hospitals across the country for two primary reasons: Emergency medicine is the only specialty with a federal mandate to provide care to patients seeking treatment. A shortage of primary care providers has forced more sick people to seek treatment in hospital emergency rooms. Common Problems with Emergency Care > >
  6. 6. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. This overcrowding leads to a number of common problems with emergency care that can be seen as markers of hospital health. Patients walking out of the emergency department without being seen. When customers vote with their feet, this presents three risk factors: ‒ Customer satisfaction ‒ Health ‒ Financial Common Problems with Emergency Care >
  7. 7. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Excessive wait times In May 2014, the Centers for Disease Control and Prevention (CDC) reported average emergency department wait times were roughly 30 minutes. Common Problems with Emergency Care >
  8. 8. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Volumes negatively impacting throughput and patient Common Problems with Emergency Care > Hospitals need a coordinated system effort in order to improve throughput, however Emergency Departments can focus on some specific metrics such as Median LOS for discharged patients, Median LOS for admitted patients, and Median LOS for behavioral health patients to improve throughput and patient experience. However, factors such as operating room schedules, inpatient capacity, and increased behavioral health problem affect volumes and throughput and need to be addressed on a system-wide level.
  9. 9. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. As the crisis of emergency care grows, hospitals have more pressure to make improvements in addition to the many other pressures facing the healthcare industry. Redesigning the delivery of emergency care involves a four-step approach: 1. Ask the right question 2. Create a vision 3. Use an analytics platform 4. Engage staff and stakeholders Redesigning the Delivery of Care Through Emergency Department Quality Improvement
  10. 10. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. 1. Begin with the bigger aim and ask: “What do we need to best deliver emergency care?”. Redesigning the Delivery of Care Through Emergency Department Quality Improvement Improving emergency care will tie into the Triple Aim of healthcare improvement: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare.
  11. 11. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. 2. Create a vision and support for a data-driven systems approach to improving emergency care. Redesigning the Delivery of Care Through Emergency Department Quality Improvement Many times, a department will embark on an improvement project, but don’t think about how it will affect the flow of other teams or departments. Instead, it can be helpful to create an ED Joint Practice Team where anyone who touches the patient is part of the care team. This helps improve communication between departments to avoid unforeseen consequences of changes to other departments.
  12. 12. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. 3. Using an analytics platform, develop an ED analytics application that provides insight into performance. Redesigning the Delivery of Care Through Emergency Department Quality Improvement If an ED with 65 beds has 130 patients come through the doors on any given day, but the OR doesn’t know, nor does the hospital care control center, the ED is operating in isolation without the ability to resolve issues or foresee them in advance. Using an analytics application such as ED Explorer, frontline leadership and executives have the ability to track throughput, and obtain actionable data necessary for demand/capacity management.
  13. 13. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. 4. Engage frontline staff, key stakeholders, patients, and families in improvement. Redesigning the Delivery of Care Through Emergency Department Quality Improvement Improving ED throughput is much more than an emergency department initiative, it must include the entire system of care for real, lasting change to occur.
  14. 14. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. To prevent the ED from operating in isolation, it’s necessary to involve hospital leadership and other frontline leaders in the improvement process. One way to do this is utilizing executive dashboards that show a snapshot of the ED performance on a regular (perhaps daily) basis. Dashboards might show C-suite how many patients are in ED, how many are waiting to be seen, wait times, and the number of behavioral health patients. Understanding ED Performance
  15. 15. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. One of the most telling metrics used in an executive dashboard is the longest wait time recorded or the longest wait time for a bed to be assigned to an admitted patient in the last 24 hours. Using executive dashboards can help keep stakeholders informed and involved. Increased leadership visibility and engage- ment can greatly contribute to success. Understanding ED Performance
  16. 16. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. In addition to the daily snapshot, executives might be given access to look ED goals, past performance, patients left without being seen percentage, and admission trends. Using an Emergency Services application such as ED Explorer can help provide the data necessary to track, trend, and predict resources need in the delivery of quality emergency care. Additionally, a robust ED analytics application allows users to identify and quantify areas of opportunity in throughput, ancillary resource allocation, utilization, and quality. Understanding ED Performance
  17. 17. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Understanding ED Performance Figure 1: Snapshot of ED Explorer analytics application that provides multiple views of data for the efficient day-to-day Emergency Department operations.
  18. 18. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. What using an analytics application does is help users understand ED performance based on data. That data can then be used to predict and improve performance. For example, using analytics, ED leaders can better understand patient arrival times and their impact on ED throughput. This data can be surprisingly predictable. Understanding ED Performance
  19. 19. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. For instance, a hospital might find that if 30 or more patients arrive within one hour of each other, ED wait times skyrocket up to two hours. Then, if 30 or more patients are checked in within an hour, the analytics application can notify relevant stakeholders and departments about surging volumes in the ED. If the ED is the frontline, the imaging department might be the next department to experience large volumes–and wait times as a result. Understanding ED Performance
  20. 20. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. In looking to tackle Emergency Department quality improvement projects, hospitals should look for high-impact opportunities. Revising high impact workflows such as streamlining registration and provider triage can have real, impactful results on ED wait times, patients left without being seen percentage, and patient experience. Revising High Impact Workflows
  21. 21. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Some of the workflow areas to focus on include: Improved triage workflow. Provide earlier access to provider using a triage advanced practitioner. Redesign discharge process to reduce non-value-added time. Implement readiness huddles. Improve response to surges in patient volume. Revise staffing patterns. Add flow coordinator during busy times to oversee hospital patient flow. Revising High Impact Workflows > > > > > > >
  22. 22. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. With a robust analytics application, Emergency Department leaders can gain valuable insights into improving staffing patterns to maximize efficiency. What department leaders need to ask is: “Do we have the right amount of staff at the right times in the right places?” What hospital leaders might be surprised to learn is that ED volumes can be surprisingly predictable. Revising Staffing Patterns
  23. 23. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Using an analytics platform, healthcare leaders can gain use following insights into volumes to help inform their staffing patterns. Identify seasonality in volume trends. Identify weeks with consistently high-volume. Utilize this data to predict upcoming high-volume periods. Adjust staffing matrix to meet trends. Use historical trends to plan for holiday or other identified periods of high census. Use historical trends to open and close sections of the ED to align with demand. Revising Staffing Patterns > > > > > >
  24. 24. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. One hospital found that the busiest day of the year was the Monday following Superbowl Sunday during a retrospective three-year review of ED census. Having access to this data and the ability to use it to identify trends, understand and respond to surges in volume, and predict the resources needed help improve the efficiency and quality of care provided in Emergency Departments. Revising Staffing Patterns
  25. 25. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Communicating leadership expectations is a crucial component of success. Because ED performance is a key indicator of hospital health, it’s necessary for hospital leaders to be actively engaged in the department and its improvement efforts. It may be helpful to identify an executive such as the Chief Nursing Officer of Vice President of Quality and Safety as an Executive Sponsor for the improvement work. Setting Leadership Expectations
  26. 26. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Additionally, keeping executives informed and involved through daily rounding, participation in surge calls if needed, and receiving daily ED performance reports. Setting Leadership Expectations
  27. 27. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. As healthcare becomes more patient-centric, it’s more important than ever to improve the patient experience. According to Becker’s Hospital Review, improving patient satisfaction begins in the ED. In order to being improving patient satisfaction in the ED, the quality of care must be consistent. Additionally, hospitals must purse patient feedback in order to identify high impact areas of focus. Improving the Patient Experience
  28. 28. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Below are some ideas for improving the patient experience in the ED: Facilitate weekly huddles to review patient feedback. Ensure leadership makes clear that patient experience is a priority for the entire team. Exchange security FTEs for “Guest Services.” Conduct patient experience training. Consider embedded care management in the ED. Have leaders perform daily rounds. Reinforce common patient experience best practices and expectations. Improving the Patient Experience > > > > > > >
  29. 29. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Mission Health faced a number of challenges in its ability to deliver effective emergency services. Large numbers of patients were walking out of the ED without being seen by a provider, and, on average, patients waited more than 50 minutes to see a qualified medical provider. They embarked on an Emergency Department quality improvement mission to improve their patient flow, patient experience, and ED throughput with a data-driven approach. Getting Results
  30. 30. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. In a little over one year, Mission Health dramatically improved all aspects of ED throughput, including: Getting Results Nine percent relative reduction in the rate of patients who left without being seen (LWBS), resulting in the current performance of 0.4 percent. 29 percent relative reduction in the time from discharge order to ED departure time. 24 percent relative reduction in the median length of stay (LOS) for patients who are discharged. Changes in triage and treating patients who are not as acutely ill in a more space-efficient environment also contributed to a decreased LOS. With these changes, patient satisfaction doubled.
  31. 31. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Although improving care in the ED is a high priority for many hospitals, it’s important to have realistic expectations and prepare for success. Emergency Department quality improvement is a journey that takes time and improving ED performance is much more than an emergency department initiative–it must involve the entire system of care. Additionally, using a data-driven approach can help engage stakeholders and make a compelling case for change. Embarking on an ED Transformation
  32. 32. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Changing the entire system of care requires excellent leadership and leaders need to pace themselves so then can effectively lead the change. Embarking on an ED Transformation
  33. 33. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. For more information: “This book is a fantastic piece of work” – Robert Lindeman MD, FAAP, Chief Physician Quality Officer
  34. 34. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. More about this topic Link to original article for a more in-depth discussion. Emergency Department Quality Improvement: Transforming the Delivery of Care 7 Features of Highly Effective Outcomes Improvement Projects Brant Avondet Healthcare Project Management Techniques: A Pragmatic Approach to Outcomes Improvement Curt Sellke , Client Engagement, Sr. Director How to Achieve Your Clinical Data Analytics Goals Elaine St. James, BSN, RN, CPHQ, Patient Safety Services; Josh Ferguson, Clinical Outcomes Improvement, Director Nancy Casazza, BSN, MMI, RN, Clinical Outcomes Improvement, Director The Top Seven Healthcare Outcome Measures and Three Measurement Essentials Ann Tinker, MSN, RN , Professional Services, Sr. VP How UPMC and Health Catalyst Improve Outcomes Using Innovation in Activity-based Costing Kyle Salyers, Sr. VP
  35. 35. © 2018 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Other Clinical Quality Improvement Resources Click to read additional information at www.healthcatalyst.com Health Catalyst is a mission-driven data warehousing, analytics and outcomes-improvement company that helps healthcare organizations of all sizes improve clinical, financial, and operational outcomes needed to improve population health and accountable care. Our proven enterprise data warehouse (EDW) and analytics platform helps improve quality, add efficiency and lower costs in support of more than 65 million patients for organizations ranging from the largest US health system to forward-thinking physician practices. Health Catalyst was recently named as the leader in the enterprise healthcare BI market in improvement by KLAS, and has received numerous best-place-to work awards including Modern Healthcare in 2013, 2014, and 2015, as well as other recognitions such as “Best Place to work for Millenials, and a “Best Perks for Women.”

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