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Studer Spotlight: Rethinking Emergency Department Results: Are You Treating Before Diagnosing?

Posted on Wed, Jul 20, 2016
Studer Spotlight: Rethinking Emergency Department Results: Are You Treating Before Diagnosing?

Since 2010, EmCare has maintained a strong partnership with Studer Group to improve clinical and operational results for our client hospitals. As a result of this partnership, Studer Group has provided access to exclusive content only available on StuderGroup.com. Each month, one of Studer Group's insightful articles will be made available to Emcare.com blog readers. For more information about EmCare's partnership with Studer Group, click here. For more exclusive content, including webinars, learning labs, networking opportunities and more, visit StuderGroup.com.

By Karen Smith, MSN, RN, CEN, NE-BC

Would you ever start an antibiotic without having a diagnosed infection? How about having a cast applied before the X-ray is taken? We expect to be examined and a diagnosis made BEFORE starting any prescribed treatment. The same approach should be taken when identifying ways to improve Emergency Department (ED) results.

Have you ever wondered why your ED does not seem to have efficient processes? Do your goals for the department seem elusive and unattainable? Are you concerned that the engagement of your staff is not where you want it to be? The problem may be that you aren’t addressing the right problems, or you are trying to treat a problem before properly diagnosing.

With many ED volumes rising1, EDs and healthcare organizations must develop and implement the right tools and skills to drive results.

Our Studer Group Emergency Department experts use a diagnostic approach to determining the individual needs of an ED. This precedes the formulation of the treatment plan and consists of four key steps:
 

  1. Assess: The first step is to conduct a comprehensive assessment of the operational flow of the ED. This includes direct observation of patient movement, review of key operational metrics, staffing patterns to match patient volumes, overall productivity, and patient survey responses.
  2. Align goals: The next step is to determine goals for the ED and how those goals will be measured. The leaders must be in agreement of the vision for the department and setting goals that align with that vision. These are the building blocks for an objective evaluation system, such as Leader Evaluation Manager® that holds leaders accountable for achieving and exceeding their goals.
  3. Align behaviors: There are certain behaviors and tactics that drive results in the correct direction. Expecting ED staff to change patterns or habits can be hard. Careful sequencing of change implementation must be accompanied by a large dose of the ‘why’ or the evidence-based reason to change. Teams will not see the full results of these changes without ensuring each are hardwired (have become habits).
  4. Align processes: Using the observed patterns and existing ED flow metrics vs. known best practices will help teams to determine which flow models need to be implemented. Splitting the flow of patients and processing them based on their assessed acuity level will ensure that every patient receives excellent care in as timely a manner as possible.

Let’s look at an example: If an ED wants to assess and treat a higher-than-average rate of patients leaving without being seen, the four steps might look like this:
 
  1. Assess: Examine the reasons why the rate is elevated based on triage process flow from arrival to being seen by a provider. Key metrics may indicate prolonged door-to-provider intervals or longer-than-average lengths of stay. Analysis of staffing to match arrival patterns must be considered as well as the efficiency of key interdependent departments.
  2. Align goals: Setting goals for improvement might include reducing the overall percentage of patients leaving without being seen and also the return-on-investment resulting from captured revenue. Leaders can then formulate specific action plans to focus their attention on the goals.
  3. Align behaviors: Our approach and communication to patients as they wait to be evaluated by a provider will directly and positively affect their willingness to wait and their overall satisfaction.
  4. Aligned processes: Implementing best practices for expedited triage and direct bedding can reduce the time interval of arrival to being seen by a provider. Other process tactics to implement could include placing a provider in triage or use of a results pending model.

Remember to connect back to the ‘why’? Reducing left-without-being-seen (LWOBS) will improve patient safety and satisfaction, increase revenue, and reduce risk when patients leave without evaluation. Plus, it will save ED staff members’ valuable time.

The results of this approach are staggering. For example, in one organization coached by Studer Group, a decreased overall LWOBS resulted in an annual savings of $289,000. In another Studer Group partner organization with an ED volume of 120,000 patients, LWOBS rates decreased by more than 50 percent resulting in an ROI of $6.4M in increased annual revenue.

High-performing EDs have mastered efficient patient flow using foundational behavioral goals and behaviors. As EDs are the front door to most hospitals, our patients deserve an evidence-based approach to their clinical care that is based on a diagnostic workup. Additionally, patient flow through the ED is also positively influenced by evidence-based processes that are part of a comprehensive treatment plan based on diagnosis.

ED providers and staff make a difference every day in the lives of patients and families. By putting these steps into place, the life you save may someday be your own!

1 ER Visits Continue to Rise Since Implementation of Affordable Care Act. American College of Emergency Physicians, May 4, 2015. http://newsroom.acep.org/2015-05-04-ER-Visits-Continue-to-Rise-Since-Implementation-of-Affordable-Care-Act

Studer Group Karen Smith

Karen has over 35 years of clinical and administrative experience, primarily in emergency departments. As a Certified Emergency Nurse and a Nurse Executive – Board Certified, she maintains an expertise in emergency care and nursing administration recognized by professional organizations.

Prior to joining Studer Group, Karen served in clinical staff roles for many years in both a Level-1 trauma center and community hospital settings. Her 10 years of direct leadership experience were at a Magnet hospital within a major hospital system in Rhode Island. During these leadership years, Karen coached staff to improve the patient experience, achieving patient satisfaction scores for nurse measures consistently in the 90th percentile or better. As an emergency department consultant, she held numerous emergency department leadership positions where she implemented measures to improve the patient experience, reduce numbers of patients leaving without being seen, and reduce door-to-provider intervals among other throughput measures.

 

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Studer Spotlight: The Patient Experience: Does this Really Matter?

Posted on Wed, Jun 22, 2016
Studer Spotlight: The Patient Experience: Does this Really Matter?

By Dan Smith, MD, FACEP

This short list includes just a few of the terms and tactics around patient experience. These previously uncommon phrases are now forefront in our healthcare playbook of goals and strategies. Let's explore the questions below:

Are the efforts to drive patient experience grounded in medical science?

A growing collection of peer-reviewed literature exists that supports the notion of patient perception of care as a marker of care quality. The CRUSADE trial studied over 6,000 acute myocardial infarction (AMI) patients and examined the mortality of this cohort as a function of their perception of care scores (Glickman et al, Circulation 2010). They also measured guideline adherence. In risk-adjusted cohort comparisons, patients with higher patient experience metrics showed lower mortality from AMI. Interestingly, their adherence to treatment guidelines was higher.

Studies looking at factors influencing hospital readmissions suggest that patient perception of care is an important predictor of readmission (Boulding et al, American Journal of Managed Care 2011). Lastly, a large systematic review of patient experience literature led by Doyle et al in BMJ Open found linkage of patient experience to favorable quality outcomes and reduction of complications of care in >77 percent of international studies (22 percent of studies found a neutral association).

The mounting data supports the notion that patient perception of care and our ability to communicate and connect with patients is an important driver of patient quality outcomes, adherence to medication and treatment regimens, and avoidance of readmissions and complications.

Will patient experience efforts help us thrive in the complex and changing world of healthcare?

Healthcare models of care have evolved and how we enumerate performance has changed:
 

Past Future
volume volume + value
health maintenance organization (HMO) Accountable Care Organization (ACO) / physician-hospital organization (PHO) /Clinical Integrated Network (CIN)
paternalistic mutualistic
usually always
effort performance
care care + perception of care

We now practice in a world of ever-increasing transparency and accountability where process of care, outcome of care and perception of care are scrutinized. Those who embrace the change, align and outperform on these evidence-based measures will not only receive full payment for services but also value-based bonuses. The recent replacement of Medicare's sustainable growth rate with the MACRA program that will be implemented over the coming years further emphasizes transparency and accountability to patients. As envisioned, MACRA has a heavy emphasis on rewarding those physicians and medical groups that receive high patient experience scores and other quality (value) measures. Those that are unable to focus on these core competencies will see significant reimbursement reductions. In a new reality of reduced operating margins from risk-withholds and complication/readmission penalties, enterprises that coach and train staff and providers to thrive in the new age will appreciate loyalty and growth, risk reduction, favorable bond ratings and market differentiation.

How can a provider accept and embrace the change?

Think about this through the lens of our customer, the patient. We are driven to understand the complexities of science and medicine and apply technical and cognitive mastery to the healing arts. Patients may not understand clinical explanation at our level but they sense kindness and empathy, which can often act as proxies to care quality and ratings of care.

Don't traverse the change alone. If you feel you received little to no training on communication skills and don't know where to begin, reach out to subject matter experts who know the evidence-based skillsets that will elevate your game in communication and connection to patients.

Embrace it, accept it and get it done. Keep it in perspective though. Truth is, you still assess and treat the patient. You still order appropriate testing and treatment. You will formulate a differential and ultimate diagnosis. Do we have to think differently about the way we communicate and behave? Yes, we do, and this is not a soft skill: the physician domain remains one of the most difficult "top box" composites in CG CAHPS and HCAHPS to elevate and sustain. Pay attention to the skill sets that beget performance on patient experience, deploy a couple tactics to improve communication (AIDET® is one) and be consistent in their use. With some practice and time, this will become the new way you communicate. Soon after, you will receive positive feedback from patients and families and you can even save time in patient interactions.

Dr. Smith has practiced since 1998 in the emergency departments of Baptist Health System, San Antonio, TX. He directed Patient Experience for Emergency Physiciansʼ Affiliatesʼ from 2007-2015. Dr. Smith is a diplomate of the American Board of Emergency Medicine and a Fellow of the American College of Emergency Physicians. He completed a residency in Emergency Medicine at William Beaumont Hospital in Royal Oak, MI where he was chief resident.

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Studer Spotlight: The Fundamentals of Emergency Department Physician Leadership

Posted on Thu, Sep 24, 2015
Studer Spotlight: The Fundamentals of Emergency Department Physician Leadership

Since 2010, EmCare has maintained a strong partnership with Studer Group to improve clinical and operational results for our client hospitals. As a result of this partnership, Studer Group has provided access to exclusive content only available on StuderGroup.com. Each month, one of Studer Group's insightful articles will be made available to Emcare.com blog readers. For more information about EmCare's partnership with Studer Group, click here. For more exclusive content, including webinars, learning labs, networking opportunities and more, visit StuderGroup.com.

By Josh Kosowsky, M.D., FACEP

We know solid physician leadership creates results that last. However, many emerging leaders start their career in healthcare or transition into a new leadership role without the skills needed to succeed. The good news is that these skills can be acquired.

Emergency Department Physician leaders require skills such as how to interpret and impact patient experience data, integrate with hospital operations and build accountability within their team. Through our work with emergency departments and thousands of leaders, Studer Group has identified the skills that separate the best physician leaders in healthcare from the rest.
 

  1. Explain the why. The healthcare industry is in a constant state of change. As a physician leader, it’s your job to help other providers become more comfortable with and adapt to change quickly. That’s why we coach leaders to always start with “the why”. By explaining why we’re rolling out a new initiative or implementing a new procedure, staff gain the reason behind the change first. Then you can share what the process looks like and how it will make an impact. Be sure to share what’s in it for the patient but also, what’s in it for the provider.

  2. Role model the change. We find that physicians and staff are more likely to change when the physician leaders they trust demonstrate the behavior. For example, if tactics such as AIDET® and Rounding for Outcomes have been rolled out, physician leaders should also use the tactics to support a culture of service. One tip is to huddle with your team at the start of each day to convey expectations, drive a collaborative relationship and create a shared effort.

  3. Round on physicians. When physician leaders round on other providers it establishes sincere communication and partnership between both leader and physician. We recommend scheduling a time at the provider’s convenience when a one-on-one meeting can be held, and physician leaders should have set questions to structure the meeting. One of the most impactful questions we suggest leaders ask providers is “What can I do for you?” This further demonstrates the physician leader’s level of caring and respect.

  4. Measure performance and share data. We often find that physicians are “knowledge rich but data poor”. In this age of transparency with data being publically reported on the Hospital Compare and Physician Compare websites, we have access to valuable information readily available. During one-on-one meetings, physician leaders should review the individual data but also comparative data as well. A dashboard is a great way to track and trend results, as well as identify the biggest opportunities for improvement. Then, identify one or two objectives to focus on moving forward.

  5. Reward and recognize behavior. As a physician leader, you may at times feel like you spend more time putting out “fires” and fixing problems than anything else. It’s important, however, to focus on what’s working well and reinforce good behavior when you see it happen. This is especially important when we’re asking individuals to change a behavior or rolling out that new procedure. Taking time to say “thank you”, both verbally and in hand-written thank you notes, sharing positive patient comments, providing an annual award or even incentive compensation are great ways to show appreciation.

These fundamentals are designed to save physician leader’s time, impact patient experiences and improve outcomes. In the process, better relationships are formed, the resistance to change is minimized and both physician leaders and providers feel a strong connection to the same goals and outcomes.



Josh Kosowsky, M.D., FACEP,  is a nationally recognized expert clinician and lecturer who serves as Vice Chair and Clinical Director of Emergency Medicine at Brigham & Women’s Hospital in Boston. A former Fulbright Scholar and a graduate of Harvard College and Harvard Medical School, he is currently holds an appointment as Assistant Professor of Emergency Medicine at Harvard Medical School.

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