ED Accreditation Update
Hospital addresses ED overcrowding, sees treatment times and walkout rates drop
While addressing the new accreditation standard for overcrowding (LD.3.11), one hospital has managed to decrease its treatment times, drop its walkout rate, improve its patient satisfaction scores, and improve its revenue capture, despite increasing patient volumes.
Mary Washington Hospital in Fredericksburg, VA, like other accredited hospitals, is required to meet the new 2005 “ED overcrowding standard” from the Joint Commission on Accreditation of Healthcare Organization. That standard requires leaders to develop and implement plans to identify and mitigate impediments to efficient patient flow throughout the hospital.
This standard was a challenge for Mary Washington, where ED visits had increased 30% from 1999 to 2003, and ED managers expect to have 85,000 visits this year. The hospital has no bypass or diversion system.
To improve patient flow, the hospital instituted a committee in August 2004 titled the “Patient Flow Excellence and Accountability Team” (PFEAT). The team included the hospital chief operations officer, multiple vice presidents overseeing operations, the chief nursing officer, all major departmental heads (laboratory, radiology, environmental services, etc.), members from industrial engineering, Bedway, ED physicians, including the department chair and Crane.
The team focused on three categories: volumes, inpatient flow, and ED throughput, says Jody Crane, MD, MBA, assistant director and business director of the Fredericksburg Emergency Medical Alliance, a private contract emergency medicine group at Mary Washington.
“Due to the typical roadblocks to getting patients upstairs, we have placed special emphasis relative to inpatient flow,” Crane says. One focus of the team is the time from when the decision is made to admit to when the patient reaches the floor, with the goal being less than one hour, Crane says. Thus far this year, the average has been 41 minutes, he says. The treat and release times have been decreased from more than five hours to three hours and 18 minutes. The walkout rate has gone from 3.2% to 2%.
Crane says capturing more than 3,000 walkouts annually, they could capture more than $150,000 in net revenues for the hospital and $300,000 in physician revenue. “This is conservative based on average net revenues and does not take in to account that most patients — about 90% in our institution — who walk out are insured,” he says. “The net revenue capture could be significantly greater if you consider the impact of increased efficiency — 16% decrease in ED length of stay — translates into 16% increase in capacity that will likely be filled.”
Getting patients to the floors quicker was achieved partially by educating the nurses and getting the nurses and supervisors to buy in, Crane says. It’s developed into a somewhat contentious relationship between the floor nurses and the ED nurses, with ED nurses insisting that they have to get patients up in an hour. “But that’s good; it’s been productive,” Crane says.
Posting data and demonstrating improvements has helped motivate the staff, says Marianna Bedway, RN, BSN, MPA, director of emergency services. The managers posted data on the time intervals for each step of the process. “As soon as we set targets and put them on a tracking grid, it almost created a Hawthorn effect,” says Bedway, referring to the quality improvement process by which simply telling people that their performance is being measured causes them to put forth more effort. “Just the setting of targets for staff to hit and clear expectations created something for them all to slide toward,” she says.
Also, administrators have walked through the department and praised employees, Bedway says. “The more recognition they got from the CEO, they responded very well and the more they wanted to do,” she says. “The more we tightened the targets, the more they wanted to do to reach the outcomes.”
Other changes include forging necessary relationships with other departments, she says. “We meet regularly with radiology, and we have a good working relationship with the lab,” Bedway says. Additionally, more point-of-care testing is being conducted, she says.
The hospital also made these changes:
• Adjusted provider-patient ratios.
An assessment conducted about 18 months ago indicated that the hospital needed to adjust the nurse-patient ratio, Bedway says. She used consultants and tools available from the Emergency Nurses Association (ENA). ENA resources include ENA Guidelines for Emergency Department Nurse Staffing. Mary Washington reduced the staffing ratio on the acute side from 1:5 to 1:4 for nurses, and from 1:15 to 1:12 for doctors. “It’s not just throwing staff at a problem,” Bedway emphasizes. “It was redefining how the process of care needed to take place and then finding appropriate resources.”
When she asked for more FTEs, Bedway also demonstrated that the staffing plan would allow the ED to see more patients, reduce the walkout rate, and improve documentation. “By nurses doing more complete documentation of care they’re providing, it helped revenue,” she says. “If you can demonstrate to administrators that you need resources to appropriate manage units of operation, it’s an investment that pays off.”
With the nurse-patient ratio reduced, the ED was better able to attract and retain its own staff and decrease use of travelers. Additionally, the ED put a nurse manager on each shift reduce the manager/nurse ratio from 1:185 to 1:60, Bedway says.
• Evaluated tools and equipment.
When the ED managers evaluated whether the staff members had the tools and equipment needed to perform their jobs, they determined that computers needed to be placed closer to the nurses. All documentation is done by computer, Bedford points out.
Additionally, equipment for trauma and codes was placed in key trauma rooms, rather than being accessible through a Pyxis machine in another location, she says. The ED also obtained a portable C arm for diagnostic work performed in the department.
Moving to wireless phones for all the nurses has improved communication, Bedway says. “The square footage of the department is pretty big, so being able to communicate is key.”
• Reworked traditional triage process.
The ED converted from a three-level to a five-level triage system, which significantly boosted efficiency for the four teams of providers, Bedway says. “It helped us better stratify care needed for patients, in terms of placing them with the appropriate team,” she says.
Also, the ED is experimenting with using a triage nurse as a “key piece” of the efficiency efforts, Bedway says. Previously, a charge nurse had responsibility for higher and lower acuity teams. “What happens in that model is that the charge nurse is focusing on the more acute team and what the rescue squads are bringing to the back door,” she says.
Under the new model, a triage nurse keeps her eyes on rooms that need to be cleaned and keeps patients flowing out of the waiting room, she says. “She’s also looking to see who has X-rays and labs back, so physicians can make dispositions of patients as well,” Bedway says.
• Improved communication with staff.
A staff survey identified a significant void in communication in terms of involving staff in decisions that would impact their practice, Bedway says.
To address that problem, the ED starting having eight monthly staff meetings held around the clock so all 185 employees could attend. “Keeping them in the loop of changes as they happen has been critical,” Bedway says.
Crane says all of these efforts have had a positive impact on the hospital’s accreditation process, including meeting the new standard on ED overcrowding. “I have no doubt they have helped us and will help us tremendously in the future,” he says.
Sources
For more information, contact:
- Marianna Bedway, RN, BSN, MPA, Director, Emergency Services, 1001 Sam Perry Blvd., Mary Washington Hospital, Fredericksburg, VA 22401. Phone: (540) 741-1180. E-mail: [email protected].
- Jody Crane, MD, MBA, Assistant Director, Business Director, Fredericksburg Emergency Medical Alliance, Fredericksburg, VA. Telephone: (540) 741-1676. Fax: (540) 741-1164. E-mail: [email protected].
ENA Guidelines for Emergency Department Nurse Staffing is available for $100 plus $20 for shipping and handling for members of the Emergency Nurses Association (ENA) and $500 plus $65 for shipping and handling for nonmembers. A licensing agreement must be signed before ordering. Call the ENA national office at (800) 243-8362 to request a copy of the license agreement.
While addressing the new accreditation standard for overcrowding (LD.3.11), one hospital has managed to decrease its treatment times, drop its walkout rate, improve its patient satisfaction scores, and improve its revenue capture, despite increasing patient volumes.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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