Patient care, efficiency helps you cut costs
It’s a mistake to look at costs without also considering patient care, argues Steven J. Davidson, MD, MBA, chair of the department of emergency medicine at Maimonides Medical Center in Brooklyn, NY. "Costs are an important driving factor in the ED. But making costs your raison d’être instead of patient care is the wrong focus for physician leadership and clinical service leadership," he says.
By reducing waits, costs are also reduced, Davidson stresses. "Patients waiting around take up resources and distract staff from their work. When a patient is there for an extra hour, they will have to be taken to the bathroom; for two hours they may need to use the telephone; for four hours you may have to give them a meal. So if you want to reduce your costs, reduce the patient’s total time in the ED."
The ED has achieved per-unit cost savings by improving efficiencies, says Davidson. "Reducing waits and delays improved efficiency and reduced costs. For example, proportionally, we do not use as many doctor hours as we did when we started our efforts," he explains.
The ED dramatically reduced costs of patients per doctor, he says. "In 1995, our ED saw 54,000 patients. To do this, we provided 100 hours daily of physician coverage and 12 hours daily of PA coverage. In 1998, our ED saw 71,000 patients, a 30% increase, yet we averaged only 104 hours of daily physician coverage and 16 hours daily of mid-level provider support," he reports.
During the same time period, the average time patients wait to see a doctor was reduced from 80 minutes to 50 minutes, says Davidson. "We improved the throughput in the ED so doctors could see more patients per hour, which reduced the cost of patient per doctor," he explains.
The hospital sees more patients and more admissions without spending more money for doctors, Davidson stresses. "Over the three-year period, the costs per hour for doctors didn’t really change, and yet the doctors are seeing 30% more patients. The cost to the hospital and the group practice per patients seen went down, even as patient acuity went up, and a greater proportion got admitted," he says.
Turn-around time nearly halved
The overall admission rate increased from 25% to nearly 29%, Davidson reports. "Our total turn-around interval nearly halved, markedly reducing waits and delays for our patients, especially those discharged. The proportion of more ill patients (as measured by admissions) in our population showed a disproportionate (33+%) increase to the increase in our total census," he says.
Mid-level providers now call nearly 35% of the patients who were seen in the ED and discharged, Davidson notes. "These calls help patients with follow-up problems and help us assure that any misses’ in the ED don’t become catastrophes for our patients," he says.
A unified management model for the ED made it easier to reduce waits and delays and impact costs, says Davidson. (See guest column on p. 45 in the April 1999 issue of ED Management on the benefits of a unified organizational structure.)
"With this model, we don’t have to pull together collaborative meetings with VPs in nursing and finance. We can make the decisions ourselves within our own unit," he explains.
When a change affected the ED’s registration clerks, it wasn’t necessary to consult the hospital’s finance department, Davidson notes. "We removed the registration booths, so our clerks actually roam the ED and can register a patient at any PC," he says. "We were able to make that change without consulting other departments."
Another key change involved the way doctors are assigned patients. "We switched from the triage nurse doling patients out to doctors, to a system used in most EDs, where the charts are stacked and the doctor picks up the next chart in order," says Davidson.
As a result, the time from the patient’s arrival until being seen by a doctor lengthened. "But we also tracked the time from when the doctor first sees the patient, until the disposition of the patient," says Davidson. "We learned that by letting the doctor pick up the charts, the sum total of that time shortened. So patients waited longer to see the doctor, but got care more expeditiously and got dispositioned quicker, and the total result was a time savings."
Use incentives to improve staff efficiency
"We have moved toward an incentive program based on the number of patients seen per hour," says Daniel DeBenke, MD, FACEP, associate professor and director of clinical services at Froedtert Memorial Lutheran Hospital in Milwaukee, WI. "Additional patients can be seen for a small variable cost, which decreases the cost per patient."
Physicians get bonuses each year based on how they compare to rest of the group. "As a result, we have improved the number of patients seen per hour from 2.6 to 3.1 in this quarter," says DeBenke. "That means decreased length of stay, better throughput, and less bed crunch and backlog."
Physicians are data-driven individuals who respond well to the incentive program, says DeBenke. "When we give them the report card showing how they compare to the rest of the group, if they’re at the bottom of list they want to be at top of the list," he notes. "Individual physician customer satisfaction numbers will be added to the incentive program."
A physician-nurse team concept was also implemented, DeBenke reports. "In the past, nursing would be assigned to a group of five rooms. That had some degree of inefficiency, because there wasn’t a huge incentive to empty out the assignment, since they’d simply get another patient," he says.
There was also no physician ownership of patients, says DeBenke. "Physicians used a greaseboard for tracking, but patients were just put up as ready’ to be seen, so whoever was able to see the patient would sign up," he explains. "But if a physician was busy or felt it was near the end of their shift, they tended to let it sit. So patients languished for a long time waiting for physicians to see them," he explains.
A team system was developed. "We have a red and blue team, each consisting of one or two residents and two nurses. Patients are assigned to them instead of using room assignments, so obviously there is an incentive for nursing and physician teams to quickly move their patients in and out of the system," says DeBenke.
Average length of stay was decreased by 20 minutes. "The time spent with each patient is less," says DeBenke. "So patients aren’t using personnel in the ED as long, resulting in reduced costs."
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