Sentara Healthcare has been exploring the link between increased patient experience and satisfaction with structured clinical performance improvement teams that address key patient concerns, like emergency department (ED) waiting times.
The effort is continuing, and the health system is applying lessons it has learned so far, says Genemarie McGee, MS, BSN, RN, NEA-BC, corporate vice president and chief nursing officer with Sentara Healthcare, a not-for-profit healthcare system serving Virginia and northeastern North Carolina. It is based in Norfolk, VA.
Sentara uses clinical performance improvement (CPI) to address patient experience and satisfaction, after the health system saw success in using that approach for financial issues. The CEO suggested applying the process to the clinical side to improve the patient experience, McGee says.
“Like any big organization we had lots of goals, but we realized that when we have 20 clinical goals we don’t make as much progress on them as we’d like. So we used this process to hone those down each year to the five to eight clinical goals we wanted to get the entire company to focus on,” she says.
“We have a matrix that helps us figure out how many patients this would affect, where we are compared to the rest of the country on this, and how we want to improve,” she adds.
From there, Sentara leaders determine the baseline on that issue and set a goal for improvement that year in each specified area, bringing together teams to work on the goals. A CPI steering committee includes a division president, a vice president of medical affairs, and a nurse executive. That committee works with the clinical effectiveness committee to lead the teams toward their goals, she says.
Sentara also uses high-performance teams that are pulled together in particular service lines, such as cardiovascular, hospital medicine, and oncology. Those teams assist with meeting the system’s clinical goals.
Readmissions, Hospice Addressed
In the past year, the health system has addressed readmission rates, along with palliative care and hospice care. One finding was that the health system provides good hospice care, but might be slow in getting patients in that care setting.
“We were getting people into our hospice system in the last 72 hours of life, and we really should get them in earlier because the hospice care has so much to offer both patients and their family members,” she says.
Readmissions were addressed by improvements in the discharge process that included assessing the patient’s ability to comply with follow-up instructions and assisting with needs like transportation whenever possible. One of the major areas addressed last year was improving emergency department flow.
Responding to patient desires to get through the ED more quickly, Sentara has set internal goals for improving the flow-through. Sentara formed an ED high-performance team that oversees the improvements.
There are separate goals for treat-and-release patients and those who are admitted, with distinct workflows for each group.
“Treat-and-admit involves the entire hospital because we have to make sure we have the right bed available to admit, and we need the hospitalists responding to the emergency department to help move patients through,” McGee says.
Sentara adopted a model developed by Kaiser Permanente, which relies on “hubs” such as urgent care centers to take some pressure off of the hospital ED. Such hubs can offer complex and urgent care around the clock. (More information on the Kaiser model is available at: https://bit.ly/2JO1ad5.)
Flow-through Goal: 120 Minutes
In 2017, Sentara set the goal of 13 of its 17 EDs meeting a through time goal of having 50% of patients seen and released within 120 minutes of arrival. The health system did not quite meet that goal, but did see meaningful improvements in 13 EDs. Sentara is pursuing that same goal this year.
“We recognized that we had some staffing challenges, so we did some significant hiring for the EDs in the past year,” McGee says. “Even without meeting that goal last year, we heard from patients that we greatly improved our ability to process them through more rapidly. Across our system, we had 113,000 hours reduced and more than 22,700 patients discharged within 120 minutes.”
The ED improvements included creating a “pivot” area for triage, where patients are interviewed to determine what kind of care they need — not just the severity of their conditions and their priority for care. By finding out more about how they are likely to be treated in the ED, patients can be directed to different tracks of care, McGee says.
“There is one track where we keep you upright all the time because we don’t really need you to take off all clothes if you need a prescription renewal or just have a sore throat,” she says. “That keeps you moving through the ED quickly and saves a lot of down time for everyone.”
Sentara EDs also use what is called a “swarm.”
“It used to be that you started by telling the triage nurse your condition and your history and allergies, and then when you got to the back you told another nurse the same story, and then you told the physician, and if we called in a consultant you told that doctor the same story,” she says. “Now when you get to the back, the whole team arrives so the nurse, the physician, and technicians hear the story at the same time. It’s things like that that have started to really improve our through time.”
Make Goals Attainable
The human behavior aspect of these processes could be difficult to change, McGee says, because people are accustomed to doing their jobs in the same way over many years; even a change that seems like common sense can meet resistance. Sentara overcomes that resistance with physician leadership and accountability for measures indicating compliance with the new procedures, she says.
Sentara has learned the importance of setting goals that are clear and measurable, rather than general goals like “improve our ED flow through,” McGee says. The system also avoids setting goals too high, which can be discouraging. Attainable goals keep people motivated to reach them, McGee says.
“It’s also very important for everyone to understand the ‘why’ of why we’re doing this,” she says. “We’ve also learned that what gets measured gets improved. It also is crucial to include frontline staff and everyone involved in the care, and we have to prioritize goals and make them relevant.
“When you have 20 important goals it is hard to get everyone motivated, but if you focus on just a few and show them why it’s important, you can get people to make real changes.”
