ED’s paradigm shift cuts costs, improves quality
Benchmarking provided tools for improvements
A quality improvement effort capped by a $9 million renovation should have put the Parkview Memorial Hospital Emergency Care Center (ECC) exactly where it needed to be. But it was not until Parkview staff and managers benchmarked regional hospitals that they were able to achieve significant improvements and savings.
In September 1995, the Ft. Wayne, IN, emergency department (ED) had just completed new construction that doubled the old ED to 20,800 sq. ft. and 46 beds. The new facility included a pneumatic tube system tied directly to the laboratory, an X-ray procedure room in the ED, a computer radiography system, a computer tracking system for ED patients, a supply inventory/order stocking system, and separate areas for specific types of patient conditions.
ED quality improvement teams had spearheaded the installation of these technologies, and even before the construction crews had put the finishing touches on the building, these systems were proving their worth. For example, "We couldn’t have made it through the last year of construction" without the ED/NET patient tracking and management system (from TENET Information Services in Salt Lake City), says Daniel A. Garman, division director for emergency services.
The new radiology system eventually would let the department cut the cycle time for X-ray patients in half; it now averages about 20 minutes. And the supply inventory/order stocking system would generate $150,000 savings in just its first year of operation. But those results were a year or more away in September 1995.
Before the full benefit of all the high-tech gizmos had developed, patients still waited an average of 90 minutes to see a doctor and slammed the facility on satisfaction surveys. Also, overtime was becoming a problem as managers struggled to keep staff ranks filled. Worse, from Garman’s perspective, the ED’s cost per patient visit was about $10 too high.
"To be competitive in the regional market, we had to be in the $60 per visit range and were close to $70," says Garman. Only about 8% of Parkview’s business is from managed care, but Garman knows that will change quickly.
New quality team formed
A new quality team, called the ECC Departmental Focused Review Team, was formed to address these problems. It consisted of three ED staff nurses, an emergency physician, three department managers, Garman, and two advisors from the hospital’s business and resource planning department. It met for two hours every Monday for nine months and was charged with evaluating and, if necessary, redesigning the emergency department.
Building on total quality management efforts in place since 1992, the team quickly identified four goals:
1. Overall cost performance would be at or below $60 per visit.
2. Patient satisfaction would be improved. (In September 1995, it stood at 46% approval, based on a Press, Ganey patient satisfaction survey.)
3. Staff and physician satisfaction would be improved.
4. Length of stay in the department would meet or exceed goals set for each of the separate areas.
Today the average ED patient is seen in less than 30 minutes, satisfaction scores hover around 86%, the cost per patient visit is just over $58 and dropping, and the department has added eight FTEs while reducing overall costs by about $422,000 during the past 18 months. These dramatic improvements resulted from the review team’s benchmarking and site visits.
Before the team hit the road, however, members spent long hours reviewing ED process flow charts and discussing just what their "business" was. They came to a conclusion that not only shifted an old paradigm but subsequently directed their benchmarking: Parkview’s ED really had two businesses, emergent care and urgent care, and each required different approaches and operations.
Armed with this new perspective, the review team sought benchmark partners that excelled in either emergent or urgent care and had significantly lower costs and higher satisfaction scores as measured by the Press, Ganey survey. The team initially identified 28 hospitals through a phone survey team members conducted. The list was quickly trimmed to three when the team decided to save money by choosing regional partners: Columbus (IN) Regional Medical Center; Miami Valley Hospital in Dayton, OH; and Community Hospital in Indianapolis.
The Columbus Regional emergency department had a high ratio of low-acuity patients because its high-acuity patients are sent to Indianapolis hospitals. At Columbus, the Parkview team saw bedside registration on laptop computers.
"We know from our surveys that patients who come to the ED expect to be put in a bed," Garman explains. By quickly putting its patients into an urgent care room and taking information at bedside, Columbus Regional’s ED staff gave the patients what they wanted and shortened the registration process. Initial information gathered at bedside goes into the ED patient tracking system. If the patient is to be admitted to the hospital, the same laptop can access the hospital’s main patient registration system.
The quality team subsequently would implement a nearly identical system at Parkview. The new system quickly slashed the hour and a half wait to see a doctor to about 30 minutes and eliminated the need for urgent care patients to walk back and forth to a central registration desk as many as four times. Because the quality teams involved in the renovation had asked the hospital’s information system specialists for input, the new and renovated ED rooms already were hardwired for computers.
Accelerated improvement technique
Also at Columbus, the team saw demonstrated what the staff called a "breakthrough" improvement. An accelerated improvement technique, it involves bringing all the "owners" of a process together for brainstorming, a quick consensus on action, and then a short (usually only a few weeks) implementation period. The Parkview review team used the "breakthrough" technique to jump-start its own bedside registration process.
At Miami Valley Hospital, the review team found that ED personnel had been trained to use scripts when dealing with patients. The scripts covered such things as waiting times, leaving against medical advice, and visitor policies. As a result of this site visit, the review team developed five scripts for use at Parkview:
• calling patients’ physicians;
• signing out against medical advice;
• explaining the ECC’s visitors policy;
• explaining the triage process;
• communicating with patients concerning privacy.
"These help the staff communicate more realistic expectations to patients," explains Garman. "Instead of a nurse saying, I’ll be back in a moment’ when she really means five to 10 minutes, we’ve trained our nurses and doctors to say things that give patients the information they need without raising unrealistic expectations. The patients are happier because we then meet their expectations."
The hospital’s education council trains the ED personnel and posts the scripts prominently in key staff areas. Garman credits the scripting with much of the big jump in the ED’s patient satisfaction scores.
Rethinking the staffing mix
At Community Hospital in Indianapolis, the Parkview team saw another ED facility with high volumes of both emergent and urgent care. At Parkview’s ED, 20% of the 53,333 visits in 1996 were for urgent care, 30% were for emergency care, and the rest were for what Garman calls "intermediate care." This was similar to the profile they found at Community.
But Community was processing its ED patients with fewer RNs and had none of the staffing and overtime problems that plagued Parkview. The difference was in Community’s staffing mix and training programs.
Although historically the RN-to-staff mix for ERs nationally has been in the 55%-58% range, the Parkview ED was pushing 70% RNs, Garman notes. Training consisted of a six-month orientation program, which contributed to "chronic overtime and staff shortages. The staff was spending more time in orientation than the ER," Garman says.
Community had a two-week training program, then recruits were paired with a veteran, who mentored the neophyte until the learning process was complete. Additionally, Community extensively cross-trained its staff, teaching technicians to do such things as drawing blood, which only RNs had done previously.
And Community was careful to adjust the level of expertise to the level of care needed, Garman adds. "Eight-five percent of the patients who enter our ED don’t need a level-two trauma nurse," he says, but when the Parkview team analyzed what Parkview’s ED nurses did, it found that they were doing too many inappropriate things, such as pushing patients to X-ray.
Through attrition, Parkview has lowered its RN ratio in the ED to around 60%, while adding four to five FTEs (mainly orderlies and technicians) in each of the past two years. In addition to adapting Community’s staffing mix, Parkview also adapted its training program, which has helped lower overtime from 8.2% of salaries paid in 1994 to 3.2% in 1996, Garman says.
The Parkview team also benchmarked automated pharmacy distribution systems at all three hospitals. Members saw three major benefits they wanted in their ED: to eliminate the need to count narcotics between shifts; to automatically link the patient to drug charges, thus reducing loss charges; and to track small but expensive equipment better. The Parkview ED has since tested two automated pharmacy systems (PYXIS and SurMed) and is in the end-stage of choosing one.
[For more information, contact Dan Garman, division director for emergency services, Parkview Memorial Hospital, 2200 Randallia Drive, Ft. Wayne, IN 46805. Telephone: (219) 484-6636, Ext. 60160. Or visit Parkview on the World Wide Web at www. parkview.com.]
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