ED Best Practices Can Help Ease Transitions Under Healthcare Reform

Four sources of inefficiency and four best practices of high-performing emergency departments

It is a common assumption that healthcare reform, by providing insurance to millions of previously uninsured individuals, will reduce volumes in the emergency departments of the nation’s hospitals. But history has demonstrated otherwise, and hospitals need to prepare their EDs to function more efficiently than ever, says Lynn Massingale, MD, FACEP, chairman and CEO of TeamHealth, a leading hospital-based clinical outsourcing firm that provides ED services to more than 400 hospitals nationwide.

"We think volumes will go up before they go down," Dr. Massingale says, using Massachusetts as an example. In that state, ED use has remained high even as more of the state's residents have gained access to insurance coverage under the state's healthcare reform initiative. Healthcare reform on a national scale might similarly encounter capacity challenges with an influx of new patients, Dr. Massingale suggests.

"All these changes represent in my opinion greater and greater financial pressure on hospitals," he says. "We don't think anyone can afford not to do all they can to get their ER tuned up right now."

One of the first steps hospitals can take to 'tune up' their EDs is to reduce the time patients and staff spend on 'non-value added' services, says Mark Harris, MD, FACEP, senior vice president of TeamHealth's Hospital Based Services division. In the ED, typically 20 percent of the patient experience is "value-added" time, while the remaining 80 percent is "non-value added" from the patient's perspective, he says. In this context, value-added means that patients are willing to pay for it and it benefits them.

Gathering data on some of the characteristics and best practices of the highest-performing EDs it manages, TeamHealth identified four areas that can be the source of unnecessary waste in the system.

1. Unnecessary processing. TeamHealth encourages hospitals to use value-stream mapping, a Lean technique to analyze process flow, to look for and eliminate non-value added services when possible. Some non-value added time – for example, patient registration – cannot be removed from the system, but other non-value added services such as waiting for a bed or waiting for triage can be reduced, and patients will be happier with their experience as a result, Dr. Harris says.

2. Unnecessary motion. Dr. Harris uses an example of a hospital that was setting up a "super track" area in its ED to quickly treat patients who did not need a lengthy stay or testing. The distance from the triage area to the intake area was 88 feet, which based on the number of patients seen annually works out to 300 miles and 900 hours of walking time per year, and $40,500 in nursing cost per year. Moving the super track next to the triage area not only reduced the nurses' workload, but it also reduced wasted time and cost to the hospital, Dr. Harris says.

3. Unnecessary searching. Each time a physician has to search for a tool, time is wasted. Even 25 seconds spent searching for a tongue depressor can add up if an ED sees 50,000 patients in a year. Hospitals should standardize the way tools and materials are stocked, so physicians and others who staff the ED can immediately find the tools they need. ED teams can use a "5 S Project" – which stands for sort, simplify, sweep, standardize and sustain — to help reduce unnecessary searching, Dr. Harris says.

4. Unnecessary waiting. There are two aspects to waiting, according to Dr. Harris. One involves visual cues, or making sure that there are cues for patients and staff to move the process along. "I can knock off 35-50 minutes [of the length of a patient's visit] by asking staff what's your visual cue that a patient is ready to go home," Dr. Harris says. Installing a discharge rack for the charts of patients who are ready to leave can serve as a visual reminder to staff that they should take charge of moving patients through the system and can reduce the average "decision to depart" wait time from 50 minutes to 12 minutes, he says. "There is nothing more irritating to a patient than waiting to go home once they've been discharged."

The second aspect of waiting involves staffing the ED appropriately for its patient load. TeamHealth calculates workload distribution models to account for service variation, nursing shift schedules and other variables and helps the hospital decide whether it might need more staff in the ED to maximize throughput.

By implementing some of these changes, EDs can significantly improve their operational metrics, according to TeamHealth’s data. One large hospital decreased its percentage of patients who left prior to medical screening from 9 percent to 0.9 percent, a decrease of 90 percent. The hospital's door-to-doc time improved from 54 minutes to 13 minutes. These operational improvements translated into more than $3 million annually for the hospital.

The best of the best
Examining the four areas above can help EDs improve their efficiency and provide patients with a more satisfying experience. Hospitals can also learn from EDs that have already gotten it right. TeamHealth conducted a study, called the Decile Project, to identify some of the common critical success factors among its top 10th percentile EDs. The high performers were EDs that had success in patient satisfaction, throughput times, core measure compliance, community reputation, growth, market improvement and administrative satisfaction.

Barbara Blevins, COO of TeamHealth's Hospital Based Services division, highlights four areas the top performers had in common.

1. Staff engagement and teamwork. This is the most critical factor identified by the top-performing EDs, Ms. Blevins says. Hallmarks of staff engagement include physician engagement, a supportive culture, supportive team members, accountability and a focus on recognition and reward for performance, she says.

2. Strong leadership. Most of the high performers identified the need to have an excellent ED medical director and nurse manager to foster success. "The staff and medical staff see them as one, with common goals and speaking with one voice," Ms. Blevins says.

3. Hospital administration support. Top performers believe their hospital's administrators understand what they do and support them in their process improvement efforts, Ms. Blevins says. Signs of support can include monthly meetings between ED and hospital leaders or outstanding relationships between members of the C-suite and the ED managers.

4. Robust communication. "Leadership communicates regularly, consistently, and they make sure staff know what's going on; they address situations and don’t ignore them," Ms. Blevins says. "They don’t avoid conflict or confrontation; they deal with issues head on." This includes making staff aware of how the ED fits into what’s happening within the rest of the hospital, she says.

Understanding the qualities that lead to a successful and efficient ED will become increasingly important under healthcare reform, Dr. Massingale notes. Whether it is working to improve the functionality of electronic health records in the ED context or trying to reduce readmission rates, hospitals are facing new challenges that will require them to improve performance at all levels and within all departments.

"It's a really exciting time," Dr. Massingale says. "It is a time that favors organizations that have gone through change and aren't terrified of it and favors organizations that aren't afraid to take risks and change the way they deliver services."

Learn more about TeamHealth.

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