See an MD in 30 minutes or get your money back
Unconventional idea that works at a NJ hospital
It almost sounds like an ad for a popular pizza chain — 30 minutes or your money back. But at CentraState Hospital in Freehold, NJ, for more than three years, the emergency department (ED) has been promising patients that they will see a nurse within 15 minutes and a doctor within 30 minutes or they don’t pay. Amazingly enough, it’s working. Fewer than 10 patients have had their bills waived, says Michael Jones, MD, FACEP, FAAEM, chairman of the department of emergency medicine at the 240-bed facility in central New Jersey.
The idea was the brainchild of the head of the Robert Wood Johnson Health Network, with which CentraState is affiliated. "I told him that even Domino’s [Pizza] didn’t do this any more, but he was insistent," says Jones. "I can tell you I had three or four sleepless nights over this."
But the more he thought about it, the more Jones thought it could work. "There are artificial lulls and booms in an emergency department," he explains. "The peaks and troughs are created by the registrar and triage nurses. Unless you have a bus accident, you don’t have multiple patients descend on you between 9:15 a.m. and 9:30 a.m. They trickle in. So now we have a program where as they come in, we get them into the department."
Triage now done at bedside
At first, it was tough. By the time a nurse had seen the patient, physicians had only seven or eight minutes to get to them. Triaging was taking too long. So the hospital created an abbreviated triage sheet, and triage is now done at the bedside. Registration occurs at the bedside as well in 90% of the cases. In the other 10%, a family member does it at the front desk.
Jones says there is a strong belief that there just aren’t enough emergency room physicians and that a three- or four-hour wait is just the norm. "But in New Jersey, at least, it’s illegal for a patient not to be seen within three hours," he says. "And this is still broken on a routine basis."
If there is a staffing issue, then Jones says EDs should just hire more staff. "I guarantee you that if you do this, more patients will come," he says. And he should know. The ED at CentraState instituted a pediatric emergency department program at around the same time the 15/30 program started. "Usually, the emergency pediatricians were in the call room watching television. So we created scripts for them and when we needed help, we got them involved as patient greeters."
One day, however, Jones was called in his office and asked to be a greeter. "I asked where the peds docs were. But they were swamped. We added a service and the patients came. I never want to hear it uttered that if an emergency department adds more docs, they won’t have the patient volume to pay for it. I guarantee that if a facility goes to a 15/30 program like us, they will take patients from other facilities. We have patients come to our ED from all over the area." Indeed, he says, patient volume in the ED has increased by around 11% per year since the program’s inception in 1998.
Jones has put his money where his mouth is and has increased staffing. Where once there were six physicians, now there are 15 physicians and four nurse practitioners. To free the physicians up for more time to see patients, there is a scribe program to handle some of the administrative paperwork that was eating into patient time. "An added bonus is that the people who do that work not only cost less per hour than the doctors, but they make sure the documentation is correct."
Preventing initial negative impression
Greeters no longer are needed in the ED. Patients typically see the physician who will be treating them. The initial meeting, which satisfies the 30-minute rule, may only consist of a physician ordering labs, "but the patient feels more comfortable knowing a physician knows something about their condition," says Jones. "I think, too, that it’s important to prevent an initial negative impression created by a prolonged wait. No matter how nice the nurse or docs are, after a three-hour wait in a waiting room, it’s going to be hard to overcome a bad feeling."
And when the deadlines aren’t met? Jones says he told the doctors that it has to be a team effort, and that all the docs on the team were to pay $50 into the hospital library fund every time the 30-minute deadline wasn’t met — regardless of which physician was responsible for the delay. "The first time it happened, I was on. I whipped out my $50 and they all realized it was for real."
Jones gets a report when the deadline isn’t met and reviews the charts with the treating physicians. The patient advocate and nurse manager are also involved, and the billing company is called and told to erase the bill. "It just isn’t submitted to the insurance company," he says.
The two other hospitals in the network that the idea was foisted upon have dropped the program, but Jones is a true convert. "We really make this work," he says.
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