Transcript Whidden Emergency Department Staffing

EMERGENCY DEPARTMENT
OPERATIONAL IMPROVEMENTS
UHC
January 27, 2010
Assaad J. Sayah, MD, FACEP
Chief, Emergency Medicine
Cambridge Health Alliance
Overview of Cambridge Health Alliance:
Provider Network
Hospital:
 3 campuses with 24-hour Emergency Services:
–
–
–

Community-based Primary Care and Mental Health
Services:
–
–

The Cambridge Hospital
Somerville Hospital (7/1/96)
Whidden Memorial Hospital (7/1/01)
services at hospital campuses
18 neighborhood health centers, 4 school-based health centers
CHAPO: Cambridge Health Alliance Physicians
Organization
–
–
Employer and contractor for MD services
Physician services organization – provider enrollment, billing,
claiming, malpractice coverage, HR support
2
Overview of Cambridge Health Alliance:
Non Provider Components

Network Health- a statewide managed Medicaid health
plan
–

Medicaid products:
Commonwealth Care products:
92,785 covered lives
68,280 covered lives
Public Health:
–
–
Includes Cambridge Public Health Department and Institute for
Community Health
Work closely with public health departments in Everett and
Somerville

Alliance Foundation for Community Health
(Philanthropy)

Academics:
–
Teaching affiliations with:



–
Harvard Medical School
Tufts Univ. School of Medicine
Harvard School of Public Health Teaching Affiliate
Training programs in social work, nursing, and
occupational/physical therapy
3
Regional Safety Net Provider

Largest proportional provider of uncompensated
care in the State.
(33% of our service volume) AND
(51% Medicaid & 28% Medicare)

Care for uninsured patients from over 257 MA
communities

Many patients travel to overcome access-to-care
barriers (uninsured or under-insured, culturally and
linguistically appropriate care)

Leading state-wide acute hospital provider of
inpatient psychiatry
–
–
–
10% of the statewide mental health discharges
33% of statewide mental health free care discharges.
greater than 33% of our patients and 57% of our mental health
patients come from outside our 7-town primary service area
4
Why Change ?





Change in Healthcare environment
Change in Healthcare reimbursement
No Growth
Poor patient satisfaction
Inefficiencies
5
Historical State
CH Registered ED Visits
30,000
28,979
28,800
•Annual visit
volume has
averaged ~28.5k
visits per year
29,100
28,510
27,983
28,155
27,500
•Through 5 mos,
volume is down
2% from the PY
25,000
22,500
20,000
FY02
FY03
FY04
FY05
FY06
FY07
Projected
All
MA
Hosp DB 20K-30K State
N=961
N=205 N=33
Cambridge Hospital 7/1/06-9/30/06
Waiting time before noticed arrival
Helpfulness of first person
Personal/Insurance Info
3
3
3
2
1
1
1
1
1
Somerville Hospital 7/1/06-9/30/06
Waiting time before noticed arrival
Helpfulness of first person
Personal/Insurance Info
27
43
42
17
28
29
34
53
59
FY07 Projected represents the fist 5 months annualized
6
Essential Elements

Leadership Team
–
–
–
–

Constitution
Alignment
Commitment
Communication
Administration Support
7
ED Vision for the Future
Current State
Process
•Patient Flow Project
•ED Flow
•Inpt. Discharges
•MD & RN communication
between ED and Inpt. Unit
•Triage/Registration
•Laboratory TAT
•Transfer Leakage
Staffing
•MD Staffing/Productivity
•Nursing
•Clinical Support
•Administrative
•Registration
Capital
Investment
•ED Information System
•Tracking Board
•Electronic Medical Record
•ED Front End Redesign
•Wireless Bedside
Registration
Future State (2-3 yrs)
•Best Practice Patient Satisfaction
•Door to Doc (30 mins / 90%)
•Increased volume and capacity
8
Staffing

MD Staffing / productivity
–
–
–
–
–
Culture
Market analysis
Comp plan
Incentive
Feedback
9
2007 Hourly Compensation
•The goal is to close the compensation gap between CHA
and competitors
•Recognizing the magnitude of the salary gap, the 2007
proposal is to reduce less than half the gap between the CHA
and the rest of the marketplace
Fully Loaded Hourly Compensation
(Includes fringe & excludes malpractice)
Gap
09.891$
Midpoint Rate
1.0 FTE (1,570 Clin Hours)
Less Fringe
Midpoint of CHA Max & Non CHA Avg.
$176.02
$276,344
($18,271)
$258,073
Midpoint $176.02
$174.06
31.351$
Proposed CHA 2007 Max Compensation
CHA Max
CHA Max
Non-CHA Avg.
Non-CHA Avg.
$255,000
CHA Max (Proposed)
CHA Max (Proposed)
10
Two Tiered Compensation
Total
Compensation
Guaranteed
Base Salary
Total Compensation




Salary Withhold
“Performance Bonus”
Salary Withhold
Market Competitive
Experience based
BC / BE
Reviewed annually
Incorporates:
–
–
–
–
Productivity
Quality
Patient Satisfaction
Citizenship
Salary Withhold
Total Compensation
Guaranteed
Base
Salary
1
11
Monthly Physician Summary
Partial FY 2006 (9/1/05-6/30/06)
Based on actual date of service, not date posted to AR
Physician Code
Physician 398922
Physician 648979
Physician 854235
Physician 576280
Physician 755663
Physician 659459
Physician 874906
Physician 555917
Physician 640499
Physician 88324
Physician 549321
Physician 870211
Physician 398703
Physician 292250
Physician 54992
Physician 66271
Physician 339564
Total Hours *Pts
31.00
104
589.00
1,871
788.00
2,070
555.50
1,268
808.50
2,013
92.00
200
72.00
176
692.00
1,674
1,160.50
2,689
1,066.50
2,417
998.00
2,002
257.00
598
96.00
186
1,542.25
2,450
1,232.00
1,948
69.50
80
27.00
30
Work RVU's Per Hour
WRVUs
FY06
Pts/Hour
179.00
5.77
3.35
3,271.74
5.55
3.18
3,962.39
5.03
2.63
2,522.03
4.54
2.28
3,630.99
4.49
2.49
402.39
4.37
2.17
313.20
4.35
2.44
2,939.17
4.25
2.42
4,894.24
4.22
2.32
4,464.97
4.19
2.27
3,616.91
3.62
2.01
913.43
3.55
2.33
331.37
3.45
1.94
4,728.41
3.07
1.59
3,151.33
2.56
1.58
155.84
2.24
1.15
53.99
2.00
1.11
WRVU/Pt
1.72
1.75
1.91
1.99
1.80
2.01
1.78
1.76
1.82
1.85
1.81
1.53
1.78
1.93
1.62
1.95
1.80
Goal
WRVU's
MGMA
%
1.0 FTE 85th % tile MGMA
9,065
8,542
106%
8,721
8,542
102%
7,895
8,542
92%
7,128
8,542
83%
7,051
8,542
83%
6,867
8,542
80%
6,830
8,542
80%
6,668
8,542
78%
6,621
8,542
78%
6,573
8,542
77%
5,690
8,542
67%
5,580
8,542
65%
5,419
8,542
63%
4,813
8,542
56%
4,016
8,542
47%
3,520
8,542
41%
3,139
8,542
37%
*99281-99285, 99291
+ 1 SD
Mean (Excluding Night MD)
- 1 SD
Weighted Avg.
5.04
3.94
2.84
2.81
2.19
1.56
1.94
1.81
1.68
7,916
6,189
4,462
8,542
72%
3.92
2.16
1.82
6,159
8,542
72%
12
Quality & PT Satisfaction
Timely Chart Completion
CHA-wide Initiatives (e.g.
CAP Antibiotic Time)
Chart Review for clinical
compliance and appropriateness
Documentation of Conscious
Sedation
Incident Review
Press Ganey by Physician
Pain Management
PT Satisfaction (by measure of
Complaints & Compliments)
PT Flow Metrics /Throughput
times
Restraints
House Staff Evaluations
Other
13
Citizenship









Staff Meeting Attendance
Committee Participation & Leadership
Team Player (e.g. shift coverage & flexibility)
Administrative Duties & Scholarly Activities
Community Involvement
Staff Compliments & Concerns
Compliance with administrative initiatives
Other non-required activities which contribute to
Emergency Medicine
Other
14
Staffing



Nursing / Other
Culture
Support
15
CH Nursing & Support Staff Benchmarks
2005 ENA Emergency Department Benchmark Survey
Current
Incremental
Authorized
FTEs
Requested
FTEs
Total
FTEs
Total ED Nursing Staff (LPN + RN)
19.46
2.65
22.11
Staff Nurse (RN)
17.36
4.75
22.11
Staff Nurse (LPN)
Nursing Assistant/Aide/Tech/EMT
Unit Secretary
2.10
5.34
3.14
(2.10)
1.68
1.07
25
,
C
H
00
1
to
Pr
op
os
ed
30
,0
00
ED Visits
-
7.02
4.21
24.50
Mean
23.10
Min
14.00
Max
37.10
Std. Dev.
5.80
No. of EDs
33
Mean
1.40
Min
-
Max
12.00
Std. Dev.
2.30
No. of EDs
32
Mean
7.00
Min
-
Max
21.50
Std. Dev.
3.90
No. of EDs
32
Mean
4.50
Min
-
Max
13.50
Std. Dev.
2.50
No. of EDs
29
16
Patient Flow Project
System Project Teams
Cambridge Health Alliance
Patient Flow is a Hospital-Wide Concern

Every hospital unit has a
part to play—the ED
cannot solve the flow
problem alone.
18
Project Charter
19
Patient Flow Project Goals






Improve patient flow on all 3 campuses
Do so in a timely, safe, effective, efficient, and
patient-centered manner
Implement best practices
Utilize improvement methodologies, tools, and
measures
Utilize a multi-disciplinary, multi-campus single
solution approach
Engage hospital staff
20
Structure






Identify common issues across the system
Consolidate various campus teams working
on the same topic
Multiple disciplines (MD,RN, Support Staff)
Coordination among the teams
Avoid redundant work
Develop aggressive timelines for
deliverables
21
Focus is Across the Continuum
22
22
Fundamental Mission of Teams
Team
Mission
ED Patient Flow
Minimize time patients spend in the ED
through the application of “best practices”
Laboratory
Turnaround Time
Manage the ordering, collecting, testing, and
verification of lab work through improved and
standardized procedures
No Delay Nurse
Report
Transport admitted patients to inpatient unit
within 30 minutes of ED nurse giving report
Physician
Admitting Orders
Expedite completion of admitting orders for
admitted ED patients
Inpatient
Discharges
Decrease length of stay through effective
discharge planning activities
23
Project Methodology
24
Recommendations

Change ED flow
–
–
–
Patient partner
Mini Registration
Triage patients in less than or equal to national
average of 7 minutes

–
–
–
Bedside Registration
Rapid assessment
Maximization of bed utilization

–
ESI
Culture change
Admissions to virtual ED beds
25
Recommendations

Redefining roles of staff
–
–
–
–
RNs and PAR IIs draw labs
Charge Nurse Role
RN’s discharging patients
Create MD Order Sets

–
This has streamlined order entry
Create RN Order Sets (MD Standing Orders)
26
Recommendations

IT:
–
–
–
–

System Integration:
–
–
–
–
–

EPIC / ASAP
Dictation
PACS
MUSE
PCP Initial notification
Heads up from PCP and EMS
Medical record access
Access to ED workup
Referral
Standardization of:
–
–
–
–
P &P, Guidelines
ED documents
Equipment
Material
27
Recommendations


Process to improve quality of care
Diagnostics:
–
–
–
–

Order sets
Pneumatic Tubes in all EDs
Labeling lab specimens with a barcode label
Receiving the specimens in the lab using a barcode wand
Throughput:
–
–
–
–
–
–
–
Early identification of admissions
Maximize utilization of all inpatient capacity
Early assignment of inpatient beds
Early handoff to the admitting service
Faxing nursing report on admitted patients
Early transport to the floors
Escalation process


Back up
Code Help
28
ED Patient Partner

ED Patient Access Representative
–
–

Ambassador to patients in the waiting area
Mini registration to facilitate patient flow
Part of a response to deficiencies in Press Ganey
patient satisfaction scores related to arrival and
personal issues
Press Ganey Percentile Rank
All
MA
Hosp DB 20K-30K State
N=961
N=205 N=33
Cambridge Hospital 7/1/06-9/30/06
Waiting time before noticed arrival
Helpfulness of first person
Personal/Insurance Info
3
3
3
2
1
1
1
1
1
Somerville Hospital 7/1/06-9/30/06
Waiting time before noticed arrival
Helpfulness of first person
Personal/Insurance Info
27
43
42
17
28
29
34
53
59
29
Rapid Assessment Overview





The purpose of the unit is to facilitate rapid
assessment and treatment at the point of arrival in the
Emergency Department
Combine Express Care and Triage to form a Rapid
Assessment Unit (RA)
Relocate Registration inside the ED (Promotes
bedside registration)
Combine nursing resources from Express Care and
Triage – offers the ability to care for multiple patients
at once
Move Physician Assistant to RA.
–
–
The role of the PA is to rapidly assess and when applicable,
treat and release the patient without entering the Acute ED.
May also play a role in the initial assessment and ordering of
diagnostics for acute patients.
30
ED Transfers
EMERGENCY DEPARTMENT PHYSICIAN COMPLETES FORM
Patient Transferred To: _____________________ Date: _________ Diagnosis: ______________
Transfer Form Developed
REASON FOR TRANSFER (check all that apply)
Bed
Availability
No  ICU  M/S  Tele bed available at home institution.
No  ICU  M/S  Tele bed available at  TCH  SH  WH
 Bed Availability Confirmed with Off Shift Manager (OSM)
Specialty Care
Availability
Specialty Care Available at Home Institution  Yes  No CHA  Yes  No
Specialty Need:
 Cardiac Cath.
 Detox
 ENT
 Neurology
 OB/GYN
 Ophthalmology  Peds
 Psychiatry
Surgery:
 General Surg.
 Hand
 Neurosurgery
 Orthopedics
 Plastic
 Trauma
 Urology
 Vascular
Imaging:
 CT
 MRI
 Ultrasound
Other Specialty Need (please explain) _________________________________
_________________________________________________________________
_________________________________________________________________
Patient /
Physician
Preference
 Patient requested to go to receiving institution.
 Patient had previous care at receiving institution.
 PCP ____________________ requested transfer to the receiving institution.
PCP Name
 Consultant ____________________ requested transfer to the receiving institution.
 Monitor External ED
Transfers (100% case
review by ED Site Chiefs)
 Understand Reasons for
Transfer
 Bed Availability
 Specialty Availability
 Patient Preference
 PCP Preference
 Other
Consultant Name
Other
Information
Relevant to the
Transfer
___________________________________
__________________
__________________
CLINICIAN
DATE
APPROXIMATE TRANSFER TIME
 Create a feedback tool to
improve services and
target opportunities to
reduce system leakage
31
Community Acquired
Pneumonia
Emergency Department
Guidance for Ordering
Chest X-Rays at Triage
For use with patients presenting with
respiratory distress or suspected pneumonia
Check All Presenting Symptoms That Apply
Fever / Chills
Shortness of breath
Cough
Change in mental status
Chest discomfort
Pneumonia suspect
If one (1) or more symptoms are
checked, determine if ordering a
chest x-ray is appropriate by
assessing the additional risk factors.
If no symptoms are checked, stop
here and care for patient according
to standard protocols.
Additional Risk Factors
Circle Score
H I ST O R Y & P H Y SI C A L
History
Men
Women
(For Men enter Age in years)
(For Women enter Age in years minus 10)
Nursing Home Resident
+10
Neoplastic Disease (active or recently diagnosed)
Liver Disease (chronic)
Congestive Heart Failure
Cerebrovascular Disease (stroke or TIA)
Renal Disease
+30
+20
+10
+10
+10
Physical Exam Findings
Altered Mental Status (acute)
Respiration ≥ 30/minute
Systolic BP <90 mm Hg or Diastolic BP < 60 mm Hg
Temp <35 C or ≥40 C
Pulse ≥125/minute
02 Sat < 90%
Date ________________________________ Time ________________________________
Revised 11/1/06
+20
+20
+20
+15
+10
+10
(<95 F or ≥104 F)
Nurse Signature ______________________________________________________________
Core Measures: In order
to improve compliance
with “Community
Acquired Pneumonia”
core measures, we
developed a triage patient
risk scoring process for
rapid identification and
management of CAP
patients
Total
Hx & PE
Score

Order CXR
if score is
70* or
greater
* The ED physician may order a CXR for patients scoring less than 70.
32
EPIC ASAP
Emergency Department
Information System
Cambridge Health Alliance
Implementation

The Phase 1 Implementation includes:
–
–
–

Electronic Triage
Tracking Board
Electronic Discharge Documentation / Prescriptions
Go Live Dates
–
–
–
TCH went live May, 2008
SH, July 2008
WH, November 2008
34
Triage & Discharge
Triage
 Meditech interface of arrival information, chief
complaints, and other patient data
 Nurses enter all triage documentation into
ASAP which makes it available to the entire
treatment team
Discharge Documentation
 Diagnosis and Disposition
 Prescriptions
 Discharge Instructions
35
Tracking Board




Enables the ED to track and record all patient
activities throughout their ED Visit beginning
with registration through departure from the
ED
As the patient status changes (waiting for bed,
waiting for provider, waiting for reevaluation,
etc.) color codes are assigned to alert staff
Results Reporting – Lab & Radiology
Orders for POC testing, urine collection, EKG
request, and safety measures are flagged on
the tracking board and checked off as
completed
36
Tracking Board
37
37
ED Manager View
38
38
ED Dashboard
39
39
Outcomes

Results are overwhelming
–
–
–
–
–
–



ED TAT reduced
A 70% reduction in the number of patients leaving without being
seen
Patients have noticed a difference
Press Ganey
The reception area has remained empty during peak times
“This was the quickest emergency room visit I've ever had”
ED Staff feels like the ED is “calmer” – less chaotic
100% of patients are registered at bedside
Budget neutral
–
–
Reallocated existing staff and space
Zero up front capital costs
40
ED Ambulance Diversion
80
Total Hours on Diversion
70
60
50
40
30
20
10
0
Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan06 06
06 06
06 06
06 06
06 06
06 07
TCH



SH
WMH
Total CHA
Ambulance diversion is not good for our patients
CHA has seen steady decreases in the number of hours on
diversion
Diversion has been eliminated at the Cambridge and Somerville
campuses and has been significantly reduced at the Whidden
41
% of Time on Diversion
9.0%
8.0%
7.0%
6.0%
4.7%
5.0%
3.5%
3.2%
4.0%
2.8%
3.0%
1.9%
2.0%
1.0%
0.0%
0.0%0.0%
0.0%
0.0%
0.0%0.0%0.0%
0.0% 0.0%
8.5%
FY05
FY06
FY06
FY06
FY06
FY07
FY07
FY07
FY07
FY08
FY08
FY08
FY08
FY09
FY09
FY09
200
180
160
140
120
100
80
60
40
20
0
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Hours on Diversion
ED Diversion Hours / % of Time on
Diversion
Total Time
% Time
42
ED Turnaround Time
43
ED Press Ganey Patient Satisfaction
Overall Mean Score
88.00
86.00
84.00
82.00
80.00
78.00
76.00
74.00
72.00
70.00
68.00
85.00
77.40
77.00 78.60 78.20
79.90
85.60
84.40
81.00 80.90
78.90
76.10
75.90 75.10
Q1
Q2
Q3
Q4
Q1 Q2
Q3
Q4
Q1 Q2
Q3
Q4
Q1
Q2
FY06 FY06 FY06 FY06 FY07 FY07 FY07 FY07 FY08 FY08 FY08 FY08 FY09 FY09
Overall Mean
Peer Group 50th %tile
44
ED Left Without Being Seen Rate (%)
5.00%
4.04%
4.00%
2.38%
3.00%
2.00%
1.33%
0.97%
1.00%
0.00%
FY06
FY07
FY08
FY09 YTD Feb
45
Historical Volume Trends
•Annual visit
volume has
averaged ~28.5k
visits per year
CH Registered ED Visits
30,000
28,979
28,800
29,100
28,510
27,983
28,155
27,500
•Through 5 mos,
volume is down
2% from the PY
25,000
22,500
20,000
FY02
FY03
FY07 Projected represents the fist 5 months annualized
FY04
FY05
FY06
FY07
Projected
46
ED Visits & Admissions
33,000
5,000
31,865
32,000
31,000
30,341
4,000
Visits
30,000
29,000
28,000
3,687
28,796
3,500
28,481
3,123
3,000
3,155
ED Admissions
4,500
2,892
27,000
2,500
26,000
2,000
FY06
Registered Visits
FY07
FY08
FY09
ED Admissions
47
Average ED Sensitive Quality Core
Measures Indicator Rates
100%
95% 94% 96%
99%
94% 94% 95%
97%
97%
90%
82% 81%
80%
70%
60%
09
Q
2F
Y
09
Q
1F
Y
08
Q
4F
Y
08
Q
3F
Y
08
Q
2F
Y
O
8
Q
1F
Y
07
Q
4F
Y
07
Q
2F
Y
07
Q
1F
Y
Q
4F
Y
06
50%
07

AMI ( ASA on arrival, B Blocker on arrival)
CAP (Abx within 4 hours, BC prior to Abx)
Q
3F
Y

48
Challenges




Sustain improvements
Keep the staff engaged
Continue to improve the system
Output output output….
49
Questions
Cambridge Health Alliance