At New York City-based Montefiore Einstein, the art and science of emergency department efficiency comes from the right pathways and communication.
“When I started my career, one of my bosses told me, ‘Janine, right now you’re taking care of 15 to 20 patients in a shift. As you become an administrator, you are going to be caring for 350,000 unique patients,'” Janine Llamzon, DNP, RN, vice president of clinical services for Montefiore Einstein’s New York City region, and assistant professor, told Becker’s. “That’s an enormous challenge, but more importantly, it’s an enormous gift to be given to us.”
The science
The science of ED efficiency is rooted in clinical evidence, clinical pathways, and treatment — knowing “how we get the patient seen immediately to keep them safe and provide the treatment that gets them into healing,” Dr. Llamzon said.
On average, U.S. systems track and report a mandatory range of 284 to more than 500 unique quality metrics to external government agencies and private payers. Montefiore Einstein’s ED service line oversees nearly a half-dozen EDs and 350,000 patients, and the broader system covers nearly a dozen EDs and more than half a million patients.
To improve its metrics, Montefiore Einstein leaders have implemented 114 quality programs, policies and protocols that are centered on protecting patients’ safety and dignity, reducing delays in care and unwarranted variation across sites, and building a sustainable and engaged emergency care workforce that can deliver scalable high-quality care.
“We’ve taken a systems engineering and structural approach to all of the different points where we have this hurry-up-and-wait mentality,” Michael Jones, MD, interim chair of emergency medicine and professor of emergency medicine at Montefiore Einstein, told Becker’s.
Dr. Jones compared the emergency care experience to a train station, where passengers rush to the station only to stare at the board and wait for their train to arrive. The team’s goal is to never let a patient see “late” on the board. Thanks to its approach, the hospital’s year-to-date left-without-being-seen rate is below 1%.
“When we compare ourselves to other urban safety-net systems in the region, there isn’t another system like ours that achieves that level of accountability and really addresses the obligation and responsibility we have to our community,” Dr. Jones said.
This “train-on-time” mentality starts with leadership.
“We have a morning huddle every day where we bring together our data scientists, physician leaders, nurse leaders and advanced practice provider leaders, and we review the stress points of the day before in a structured and organized way,” Dr. Jones said.
This team approach carries over to the bedside. The physician, nurse, technician and even registration associate or security officer approach each patient together.
“We present as a team, not as a fragmented approach, and we have a coordinated pathway for how to address and manage the patient,” Dr. Jones said. “Before we start, we take time to briefly huddle. If we’re in the middle of care and need to course correct, we pause and huddle. And at the end of caring for a critically ill patient, we huddle afterward to make certain that, one, we addressed all the challenges and issues the patient is having; two, everyone’s voice has been heard; and three, we’re all aligned on the pathway going forward.”
The art
The art of emergency care rests in the ability to acknowledge the patient.
“The art is the judgment and compassion we give our patients. Compassion means being able to act on it, holistically, so that we can provide healing for them,” Dr. Llamzon said. “It’s how we notice subtle changes in patients in the emergency department, listen to a worried family and help them through complex care needs, and it’s knowing when to escalate.”
It’s also being able to pause when a patient dies, recognize their life and allow that to help transition to caring for the next patient, she said.
“The metric isn’t just ‘OK, another mortality in the emergency department; how do we get better?'” Dr. Llamzon said. “It’s also being able to touch and experience what it means to care for a patient, even in their last breath.”
For teams, the art of care includes creating leaders at the bedside who can be catalysts for improving care in the ED, Dr. Llamzon said. Dr. Jones added that the same team-based communication approach scales across the system’s nearly a dozen EDs.
“It’s really about results that we want to feel, and that we want the patients to feel,” Dr. Llamzon said.
