Is your ED a medical department or a business? Survey says . . . both
Best practice improves more than just the bottom line
What are the leading ED best practices in large health systems? According to one national survey, they include taking a business-like approach to the management of the department. The survey identified these three top best practices:
- Stronger strategic planning to solve the root causes of key ED issues, such as throughput, patient satisfaction, and capacity.
- A corporate executive designated to oversee ED management and performance systemwide, considering it a core business area.
- Greater use of information technology (IT) solutions.
The national benchmarking study was undertaken by The Health Management Academy, a Washington, DC-based organization that enables senior executives of the country's largest health systems and corporations to exchange best practices and benchmarking information. It was sponsored by Wakefield, MA-based Picis, a global provider of information solutions. Participants included more than 60 hospitals representing more than half the revenue generated in the United States.
When it comes to having a corporate executive oversee ED management and performance systemwide, it might appear that only larger systems would have the need for such a position. But in interviews with several ED managers, ED Management discovered that hospitals are appointing ED managers with significant business expertise to improve operations, medical care, and staff effectiveness.
"I think of this job as having four components: quality and safety, patient satisfaction, financial management, and throughput," says Kristin Winbigler, MBA, director of the ED at Stamford (CT) Hospital. Winbigler has her own theory on why finance is given short shrift by many ED managers. "Historically, the ED does not make money anyway, so often people just don't worry about it," she offers.
When it comes to a "corporate" ED manager, you can't get much more corporate than Justin Chang, MD, of Denver. Not only is Chang the ED medical director for the Exempla St. Joseph system, which has three EDs in Denver, but he also serves as chief of emergency services for Kaiser Permanente of Colorado, where his responsibilities include overseeing and keeping track of the ED usage of the nearly 400,000 or so Kaiser Permanente members within his EDs as well as in surrounding facilities not within his system.
Chang, who assumed his position with Exempla about eight months ago, was fortunate when it came to finances. Operations and finances were in good shape at the three facilities, he says. Nonetheless, he still approached his new position — in part, at least — as that of a corporate executive. "While the finance part was fairly stable, the service part was very low," notes Chang, adding that his three key pillars of ED management are service, quality, and finances. "Departmental patient satisfaction scores were in the single-digit percentile," he recalls. "It was only a matter of time before poor service significantly impacted the finances."
The way Chang chose to get involved was from a very business-oriented fashion. "I looked at the entire customer-consumer experience from start to finish," he recalls. Chang and the nursing manager reviewed courses on recruitment, employee retention, and customer service. "We gained a new understanding of the importance of hiring for the right fit, for training, and for rewarding those that are high performers and encouraging low performers to perform somewhere else," he says.
Hiring for the right fit, he explains, begins with a cultural fit interview. "You run through certain service line scenarios and ask how they would respond and try and find that fit. You have to get away from just hiring for a warm body," he says. So, for example, Chang might ask the interviewee to recall a specific scenario where he or she failed to meet a patient's expectations. "We try to find out what that concept means to them and what they learned, or didn't learn, from the experience," he explains. "We all generate patient complaints; I want to know how someone responds to them."
Chang also "turned it up a notch" in terms of performance management expectations, which he calls "Business 101." Because billing and coding practices were very good, his evaluations shifted entirely from the previous emphasis on areas such as Relative Value Units (RVUs), billing, coding, and chart completion, and toward more service-oriented evaluations such as patient and staff complaints, patient compliments, and satisfaction scores at the individual physician level.
"Many physicians still feel very uncomfortable with focusing on this area of their job, but it is one of the most crucial parts of running a service industry," says Chang. It is still early, but the results have been dramatic, says Chang, noting: "By the end of last year, departmental satisfaction scores had reached as high as the 95th percentile."
In addition to departmental patient satisfaction scores, Chang uses an independent service supplied by Kaiser Permanente that mails out surveys to individual patients seen by ED physicians. Here, his two positions overlap, as nearly 60% of the patients seen in his ED are Kaiser patients. The patients are asked questions such as how well the physicians communicated and how they rate their overall experience.
"I also judge the staff on judicious utilization of resources," adds Chang. "I measure their utilization of very expensive testing such as CAT scans, MRIs, ultrasounds, and certain lab studies." Here, he says, he must walk a fine line, because from a strictly financial standpoint a hospital might say, "The more tests, the better." However, Chang notes, "We know it's not necessarily good for the patient." He adds it's too early to tell whether utilization has improved.
Chang hopes to encourage poor performers to move on by getting the better performers to reach even higher levels, so that "the gap becomes so much greater that ultimately the lower performer is found to be unacceptable."
How does he hope to accomplish this? "We don't have a lot of money for bonuses, but the little I have is targeted along the lines of service-related behaviors, such as physician discharge callbacks," he explains. "It's equally important that frontline staff — nurses and techs — can share in the rewards, so we're working on that as well."
Good documentation is good for care, business Bottom line-oriented ED managers recognize that proper documentation, especially when it comes to billing and coding, can make a big difference when the department's results are tallied. It also creates the data elements needed to manage the large service line that is the ED. "You can't impact your payer mix, but what you can do is have a charge structure," says Kristin Winbigler, MBA, director of the ED at Stamford (CT) Hospital. In her model, which is essentially driven by nursing documentation, she assigned certain procedures, tests, and assessments a point value and entered them into the computer system. Level I is very minor, and Level V is the most serious. At the end of the visit, the computer totals its point value. "This is a little more corporate," she says. "It's more likely an MBA would do this, but I believe it has to be part of what you look at." Using this system, the reimbursement is naturally higher for a Level V visit than for a Level II visit, which is where accurate documentation comes in. "Nurses do not like to talk about money, but they do like to be paid," notes Winbigler. "What I want is for the organization to be credited with the work that's been done." Getting nurses to document accurately is a long process, Winbigler concedes. "The educator and nurse manager will audit charts periodically, and if they think a person is struggling, they will provide additional education," she says. Michael Jones, CCS, the ED administrative director at Howard University Hospital in Washington, DC, has a clinical audit specialist who handles quality assurance for his department and performs a complete medical record review of all patient charts, but he's not satisfied with stopping there. "My unit secretary has audit file responsibility, too — a sort of 'check-the-checker' system because of the complexity of requirements," he reports. Specific coding guidelines are followed, Jones explains. "We try to be 100% accurate" with coding, or as close as possible." "They look for complete history, complete physical, and complete review of the systems," he says. "They've been taught and trained to inform the physician [of deficiencies] directly." Having the clinical audit specialist alone has increased reimbursement revenue between 5% and 8%, he adds. Jones also trains the physicians independently on the requirements of payers. "They get a day-to-day update as to what is required to get the highest reimbursement," says Jones, noting that he communicates by e-mail and in person. |
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content