Quality Matters FM:4-10-09 4/10/09 12:41 PM Page i Quality Matters: Solutions for a Safe and Efficient Emergency Department By Shari J. Welch, M.D. Foreword by Nichloas Jouiles, M.D., F.A.C.E.P.
Quality Matters: Solutions for a Safe and Efficient Emergency Department Senior Editor: Ilese J. Chatman Project Manager: Meghan Anderson Publications Manager: Paul Reis Production Associate Director: Johanna Harris Editorial Associate Director: Diane Bell Executive Director: Catherine Chopp Hinckley, Ph.D. Vice President, Learning: Charles J. Macfarlane, F.A.C.H.E. Joint Commission/Joint Commission Resources, and External Reviewers: Cory Franklin, M.D., Michael Youssi, M.D., Catherine Chopp Hinckley, Ph.D., Diane Bell, Paul Reis, Mark Schario, M.S., R.N., Donna Tiberi-Blaszczyk, R.N., M.H.A. Joint Commission Resources Mission The mission of Joint Commission Resources (JCR) is to continuously improve the safety and quality of care in the United States and in the international community through the provision of education and consultation services and international accreditation. Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of the Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process. The inclusion of an organization name, product, or service in a Joint Commission Resources publication should not be construed as an endorsement of such organization, product, or services, nor is failure to include an organization name, product, or service to be construed as disapproval. 2009 by the Joint Commission on Accreditation of Healthcare Organizations Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission), has been designated by the Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from the Joint Commission. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Printed in the U.S.A. 5 4 3 2 1 Requests for permission to make copies of any part of this work should be mailed to: Permissions Editor Department of Publications Joint Commission Resources One Renaissance Boulevard Oakbrook Terrace, Illinois 60181 permissions@jcrinc.com ISBN: 978-1-59940-237-6 Library of Congress Control Number: 2009925557 For more information about Joint Commission Resources, please visit http://www.jcrinc.com. ii
Content About the Author................................................................ iv Foreword......................................................................... v Introduction...................................................................... 1 Acknowledgments................................................................ 4 Part One: Understanding Quality Improvement in Emergency Medicine Chapter 1: The Performance-Driven Emergency Department.................................. 9 Chapter 2: The Case for Quality Improvement in Emergency Medicine......................... 19 Chapter 3: The Case for Standardization in Emergency Medicine.............................. 27 Part Two: Your Emergency Department Quality Improvement Toolbox Chapter 4: Launching a Quality Improvement Program for the Emergency Department............ 39 Chapter 5: Quality Improvement Methodologies: An Emergency Department Quality Improvement Toolbox................................................ 71 Chapter 6: Demand Capacity Management............................................... 85 Chapter 7: Statistical Process Control................................................... 97 Chapter 8: Change Management...................................................... 107 Part Three: Patient Flow Chapter 9: Patient Flow............................................................. 119 Chapter 10: Intake................................................................. 131 Chapter 11: Throughput............................................................ 153 Chapter 12: Output................................................................ 179 Part Four: Advanced Topics Chapter 13: Patient Satisfaction....................................................... 187 Chapter 14: Patient Safety in the Emergency Department................................... 197 Chapter 15: Reliability in Emergency Medicine.......................................... 205 Chapter 16: Strategies for High-Volume Emergency Departments............................ 217 Chapter 17: Putting It All Together.................................................... 229 Index.......................................................................... 235 iii
Quality Matters: Solutions for a Safe and Efficient Emergency Department About the Author Shari J. Welch, M.D., has been a practicing emergency physician for more than 20 years. Dr. Welch writes a regular column in Emergency Medicine News, and has recently coauthored a book on patient flow. Her research has been published in The Joint Commission Journal on Quality and Patient Safety, the Academic Emergency Medicine journal, the American Journal of Medical Quality, Annals of Emergency Medicine, isixsigma Healthcare, the Journal of Emergency Medicine, and the Journal of Healthcare Quality. Dr. Welch s quality improvement (QI) research was also presented at the research forum of the American College of Emergency Physicians and at the Robert Wood Johnson Urgent Matters conference. Dr. Welch has 10 years of experience as the QI director for the emergency department (ED) at LDS Hospital in Utah and as a QI consultant for Utah Emergency Physicians. She has served as a clinical faculty member at the Institute for Healthcare Improvement in the ED Innovation Community, and she is currently a research fellow at the Intermountain Institute for Healthcare Delivery Research. iv
Foreword Emergency department efficiency for many, this phrase is an oxymoron. Many influential leaders still believe that the emergency department (ED) can be filled with patients without insurance, patients without real emergencies, and patients who will lose money for the hospital. Nothing could be further from the truth. Much research has been published dispelling these myths. But there is a striking need for more education. Here is where this book Quality Matters: Solutions for a Safe and Efficient Emergency Department enters. This book is a must read for anyone interested in improving the systems needed to provide optimal patient care in the ED. And who would be interested? Let s start with the 120 million Americans who receive care every year in our nation s EDs. They want immediate access to higher quality, efficient care. Any system that adopts the themes mentioned in this book will go a long way toward delivering excellent care. Patients will benefit, and hospital administrators stuck in a time warp with incorrect impressions of the ED will learn that the ED is a necessary part of the hospital s mission a place that can provide not just goodwill and saved lives, but can contribute to the margin. Why is this book important now? Because we face a crisis in our health care system and the ED is the poster child for all that is wrong with that system. First, the ED has never been adequately funded. Second, the physicians needed to provide care have had to rely on cost shifting to cover their extraordinarily high fixed costs. Third, a concerted effort by insurance companies and trial attorneys has misdirected resources away from patient care into corporate profits. The result is our current health care system, which places the ED in crisis. Every system is perfectly designed to achieve exactly the results it gets. This is a slogan often repeated by people interested in health care quality, patient safety, and performance improvement. When defects occur in the operations of the ED, they occur as a result of process problems not people problems. Always, the solutions are system fixes and process changes. Improvement in the ED is linked to improvement in hospitalwide patient flow. The ED is part of the overall hospital, and almost all ED patient flow problems are symptoms of operational problems throughout the hospital. ED improvements occur by employing improvement methodologies and change management. The fundamentals of performance improvement, how to design projects and carry them out, and how to run a pilot study are all important factors in improvement and change. This book is an excellent road map for making these improvements. Make no mistake this is a system issue. And although individual hospitals cannot directly solve our national issues, they can and should adopt the ideas presented here. This book is a clear and well-written discussion of how care in the ED can be made more efficient. It looks at boarding (which causes increased morbidity), mortality, and hospital stay. Fact: Elders who are boarded are more likely to go to a nursing home. Fact: There have been more than 200 deaths from boarding. Improving operations in the ED, and more importantly, hospitalwide systems efficiency will help eliminate boarding, which will improve patient care and patient satisfaction. Eliminating boarding will keep the hospital prepared for the next major disaster or terrorist strike. v
Quality Matters: Solutions for a Safe and Efficient Emergency Department Because the ED is one of the doors to the hospital, isn t it time to pay attention to improving ED efficiency? In many hospitals, the majority of admitted patients are first cared for in the ED. Starting cutting-edge care early in the process for patients improves long term outcomes that can benefit society and make an excellent business model for the hospital. So I encourage you to read this wonderful book. It is an expert s view on how to improve ED efficiency. It will help preserve access to emergency care when Americans need it. It will help the hospital s bottom line. It will help improve our nation s health care system, and it will help save lives. Nicholas Jouriles, M.D., F.A.C.E.P. President American College of Emergency Physicians Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy/ Akron General Medical Center vi
INTRODUCTION Introduction Many initiatives today address quality of care, as many of the nation s health care organizations strive to provide care that is safe, effective, patientcentered, timely, efficient, and equitable. Patient care and treatment that is delivered in the emergency department (ED) must address these same goals on a daily basis. An immediate focus on the organization s policies and procedures, new strategies, and data-driven, evidence-based care should be evident in the care experienced by patients visiting the ED. Until comprehensive quality improvement (QI) strategies are established in the ED that are based on definitive data for the purpose of providing a higher quality of care, the health care industry cannot say with certainty that quality matters in the ED. Delays in care and treatment due to an overcrowded ED or a patient bypassing a busy physician s office, for example are not only inconvenient to individuals seeking care and important to the ED environment, they could result in further patient illness or death. In fact, 7.8% of health care organizations reporting sentinel events to The Joint Commission since January 1995 have indicated delays in care as a source of the events. 1 In addition, a Joint Commission patient flow standard requires hospitals to plan, implement, monitor, and measure patient flow activities related to the following: Admitted patients who are in temporary bed locations, such as the postanesthesia care unit or the ED Patients who are placed in overflow locations Ambulance diversions The supply of available patient beds Efficiency of areas where patients receive care, treatment, and services Safety of areas where patients receive care, treatment, and services Access to patient support services The situation has not improved in recent years. In 2006, the Centers for Disease Control and Prevention reported that there were 119.2 million visits to hospital EDs, or 40.5 visits per 100 persons. 2 EDs provided unscheduled care for a wide variety of persons for reasons that range from sudden cardiac arrest or severe injury to minor acute problems that occur after business hours or for which a patient was unable to access a primary care provider in a timely fashion. In 2005, approximately one-fifth of the U.S. population made one or more ED visits, and some subgroups, such as infants, persons 75 years and older, Medicaid beneficiaries, and African Americans, had higher utilization rates than others. 2 When hospitalwide patient flow is impeded, the ED becomes overcrowded, and patients are often boarded until inpatient beds are made available for their use. Such patients require treatment space (often found in nontreatment areas), equipment, and staff time, further shrinking ED resources. In a point-in-time survey of nearly 90 EDs across the country on a typical Monday evening, 73% reported boarding two or more inpatients. 3 Moreover, 59% of EDs reported routinely using corridors for treatment, 38% reported admitting more patients than there were available beds, and 47% reported using nonclinical spaces (including offices, storerooms, conference rooms, and even showers) for patient care. 3 1
Quality Matters: Solutions for a Safe and Efficient Emergency Department Patient flow and other problems that arise in the ED can be improved by utilizing the right QI strategies, increasing data management efforts, and developing the right QI portfolio, based on the needs of your specific hospital ED setting. The causes of ED overcrowding are found in both the inpatient and ED sides of the health care equation. Therefore, the solutions can also be found throughout the organization, and this book touches on the system changes currently being trialed to ease the ED burden. The Purpose of This Book Many hospitals are struggling with operations in the ED. Problems such as boarding, capacity, diversion, patient flow, and patient safety appear to be universal in all ED settings, and current solutions to these issues are not always sufficient. Quality Matters: Solutions for a Safe and Efficient Emergency Department concentrates on practical solutions to the ED environment by providing real-world examples of common problems that occur in most EDs. It includes the following helpful information and resources: Specific solutions for solving the most common operational problems in the ED Real-world approaches to QI in the ED Performance improvement projects outlining the use of QI ideas Practical solutions that can be adapted to most EDs and that allow users to develop a portfolio of improvement ideas and a prototype project for implementation in their ED Audience The audience for this book includes chief executive officers and administrators, physician leaders, patient safety officers, QI leaders and managers, and leaders in all aspects of emergency care in the ED environment. Overview of Contents Part One: Understanding Quality Improvement in Emergency Medicine Part One provides background information for understanding and beginning QI programs and efforts. Chapter 1, The Performance-Driven Emergency Department, outlines and defines a comprehensive QI program and introduces the concept of using benchmarking, definitions associated with benchmarking, and how data helps prepare the ED for the QI journey. Chapter 2, The Case for Quality Improvement in Emergency Medicine, presents a sneak preview of the types of performance measures being considered by the Centers for Medicare & Medicaid Services, The Joint Commission, and other agencies. It includes a discussion of how to collect data and the importance of initiating a QI program. Specific performance measurement tools that can be used in data collection are also illustrated. To provide a financial case for implementing a QI program, Chapter 2 also illustrates the financial costs of patients walking out of the ED before being discharged by a physician. In addition, this chapter explores the costs of customer complaints, improvements that can be made in customer service, and patient safety advantages to having a robust QI program. Chapter 3, The Case for Standardization in Emergency Medicine, provides a controversial discussion of standardization that is imperative to any book about QI. This chapter discusses the arguments for and against standardized clinical care protocols and processes. Part Two: Your Emergency Department Quality Improvement Toolbox Part Two provides your organization with a blueprint for setting up a QI program, a brief overview of the methodologies currently used for QI initiatives in health care, and background information on implementation and change management. Chapter 4, Launching a Quality Improvement Program for the Emergency Department, provides detailed how-to methods of implementing a QI program. Suggestions on how to organize data are offered, as well as step-by-step instructions for implementing performance improvement projects. Additional resources are 2
INTRODUCTION provided in this chapter, including benchmarking data and worksheets for organizing census data, metrics, and other elements of a comprehensive QI program. In addition, this chapter includes a portfolio of quick, innovative QI projects that can be completed in less than six weeks, as well as more comprehensive projects designed for rollout over six to nine months. This portfolio of projects includes aim statements, metrics, ideas for data collection, and change ideas. This portfolio makes it possible to jump-start your QI work with real, visible, and tangible improvement. Chapter 5, Quality Improvement Methodologies: An Emergency Department Quality Improvement Toolbox, provides a review of the most common improvement methodologies in use and includes examples of successful utilization of each methodology. This chapter also provides worksheets for performing Six Sigma projects and instructions on flow mapping. Chapter 6, Demand Capacity Management, presents an introduction to demand capacity management, with a number of practical applications of these strategies for the ED. How do you match variable capacity to fixed demand? To answer this question, some ideas can be borrowed from other service industries and organizations and applied to the ED. A brief discussion of statistical process control is included in Chapter 7, Statistical Process Control, to engage your organization in this new way of looking at ED performance. This chapter includes an example that shows how simple time series data in a line or bar graph could be misinterpreted if an organization does not use statistical process control to account for variation. The text and the concepts are presented in a very simple and easy-to-understand manner. Change management has been studied and understood in service industries and by management for decades. Chapter 8, Change Management, includes a comprehensive discussion of change management in EDs. Understanding the physician culture, the change team, and how physicians can be leaders in change management are discussed in this chapter. The need for physician buy-in and engaging physicians in the quality agenda is also addressed. The chapter also includes a tool for articulating change management plans for a project. Part Three: Patient Flow Part Three provides an introduction to and a comprehensive discussion of patient flow. The concept of hospitalwide patient flow is introduced in Chapter 9, Patient Flow. Innovations such as multidisciplinary rounding, scheduled discharges, coordination of surgery schedules, the full capacity protocol, and discharge management are discussed as examples of how to improve patient flow in the ED. A case report of how one organization began coordinating the surgery schedule with anticipated emergency surgeries is examined. Chapter 10, Intake, examines the intake process, how and why this process could change in today s high-volume EDs, and some of the newest innovations to improve intake. This chapter describes physicians in triage, team triage, no triage, and abbreviated triage, along with tools for streamlining the triage process. A very brief review of queuing theory and how increasing saturation of the system could result in exponential increases in wait times is discussed. Hand-in-hand with these concepts is a review of the psychology of waiting, and this chapter includes a presentation of ideas for managing waits more effectively. In addition, this chapter discusses the concept of forecasting and how it is being applied to ED patient flow. On a very practical level, a focus on the intake portion of the ED visit and advanced triage order sets are discussed, and a variety of order sets are included at the end of the chapter. Chapter 11, Throughput, looks at throughput and some ideas for improving patient flow in the ED. Ideas such as queuing mechanisms, data dashboards, and real-time process improvement are presented with a case report example of applying this theory. In addition, demand capacity 3
Quality Matters: Solutions for a Safe and Efficient Emergency Department management strategies used by service industries are discussed for the ED to consider. The use of subcycle data to undertake metric-driven management is also discussed. A new patient flow coordinator position has been created to monitor patient flow in the ED, and this chapter discusses the responsibilities of this position. Finally, this chapter discusses new service line models. Chapter 12, Output, takes a look at patient flow output. This chapter reviews ED innovations for getting patients discharged and newer practices, such as discharge teams, discharge waiting rooms, streamlined preprinted paperwork, and discharge kiosks. In addition, this chapter discusses ways to speed up admissions. Part Four: Advanced Topics Chapter 13, Patient Satisfaction, presents an indepth discussion of patient satisfaction in the ED. This chapter reviews the elements that influence whether a patient will be satisfied with his or her ED encounter from how patients like their physicians to dress to the affects of a visible security staff. Chapter 14, Patient Safety in the Emergency Department, provides an introduction to patient safety, including human cognition and medical errors, and outlines concrete examples of aviation and anesthesia s responses and approaches to errors provide a framework for the type of research and work that could be expected in the ED in the coming years. An important part of patient safety is reliability. Chapter 15, Reliability in Emergency Medicine, defines reliability, discusses related concepts and strategies, and provides resources. The chapter emphasizes the relationship between reliability and patient safety, and it presents a model for ED reliability. This chapter will also help in understanding the QI projects listed in the Additional Resources section in Chapter 4, which are constructed using reliability tools and concepts. Chapter 16, Strategies for High-Volume Emergency Departments, describes strategies for high-volume EDs. Chapter 16 includes a review of the concept of teamwork and team behavior and discusses how they come to bear on the ED environment. This chapter offers a new practice model for emergency medicine, involving teamwork, communication, and reliability tools. Also included in this chapter are an outline of various patient assignment models and a preview of what an ED s operations could possibly look like in the coming decade. Finally, Chapter 17, Putting It All Together, provides a real-world case report example on the importance of data management and illustrates how to use elements from each of the previous chapters to implement a QI initiative, using change management. Acknowledgments Joint Commission Resources thanks reviewers Cory Franklin, M.D.; Michael Youssi, M.D.; Catherine Chopp Hinckley, Ph.D.; Diane Bell; Paul Reis; Mark Schario, M.S., R.N.; and Donna Tiberi-Blaszczyk, R.N., M.H.A. 4
INTRODUCTION References 1. The Joint Commission: Sentinel Event Statistics, Jan. 30, 2008. Oakbrook Terrace, IL: The Joint Commission. http://www.jointcommission.org/sentinelevents/ Statistics/ (accessed Jan. 30, 2009). 2. Pitts S.R., et al.: National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. National Health Statistics Report 7:1 39, Aug. 8, 2008. http://www.cdc.gov/nchs/data/nhsr/nhsr007.pdf (accessed Sept. 22, 2008). 3. Schneider S.M., et al.: Emergency department crowding: A point in time. Ann Emerg Med 42(2):181 184, 2003. 5