Transcript ED Performance: Behind the Numbers

Emergency Department Performance:
BEHIND THE NUMBERS
Todd Lang, MD, MBA
Medical Director of Emergency Services
Baptist Memorial Hospital-Memphis
Observations
“Every system is perfectly
designed to get the results it gets.”
—Dr. Paul Batalden
“It’s not luck.”
—Eliyahu Goldratt
“’Try Harder’ is not a tool for
performance improvement.”
—Dr. Todd Lang
Agenda
1. Paint a picture of a dynamic and organic
organism that operates according to the
goals set for it
2. Demonstrate Little’s Law for servers
3. Discuss some common ED metrics and their
consequences
4. Set a simple path forward
Mountain bike parts: pick two
• Light
• Cheap
• Durable
•$8899
Healthcare: We want it all, yesterday,
every time, and “all” grows every day.
Inverted U-shaped curve:
Patient experience and speed of care
Overall Satisfaction
Perfect Stay
Total Length of Stay
Tensions
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D2D vs. LOS
LWBS vs. LOS
Clinical care vs. patient satisfaction
Doctor work vs. nurse
Nurse vs. tech/paramedic
ED work vs. ICU or Hospitalist work
Perception: Listened to me vs. pushed me out the
door
• Speed and patient satisfaction
• Hospital payroll vs. contract group payroll
The ED Care Team
ED Care
Team
D2D
Core Measures
Sepsis, AMI,
Stroke
Moral distress
Moral distress occurs when one
knows the ethically correct action to
take but feels powerless to take
that action.
Do we cause this with our
leadership and expectations?
Little’s Law: Match demand and capacity.
• Server capacity x cycle time = Work In Process
• Arrivals per hour x LOS = Patients in the ED
• Apply it to the whole ED or Unit
• Apply to each pod or doctor or nurse
• Go to Wikipedia!
Sample doc calculation Using Little’s Law
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LOS = 4 hours
Doc sees 2 pts/hr (on average)
2 x 4 = 8, but if can see 3/hr then 3 x 4 = 12
Need 8 beds to be busy IF AT AVERAGE
• Doc work ends at admit order (not true for nurse)
• Some patients are easier, and some days there
are holds, so need a few extra beds
• So, need 12 - 14 beds per doc to account for this
• But, 16 is unmanageable in most situations
Can nurses do the work expected of them?
4 HR LOS Nursing Shifts
admit 4.5hr admit 4hr DC 3.5hr DC 2hr
4.5
4
3.5
Shift Time Bed 1
Bed 2
Bed 3
Bed 4
0:00
15 dirty
15
0:30
5
15 dirty
1:00
15
5
15 dirty
1:30
5
15
5
2:00
5
5
15
2:30
5
5
5
3:00
5
15
5
3:30
5
5
5 dirty
4:00
30
15
15
4:30 dirty
dirty
dirty
5:00
15
15
15
5:30
5
5
5
6:00
15
15
15 dirty
6:30
5
5
5
7:00
5
5
5
7:30
5
15
5
8:00
5
5
15
8:30
5
30 dirty
dirty
9:00
30 dirty
15
9:30 dirty
15
5
10:00
15
5
15
10:30
5
15
5
11:00
15
5
5 dirty
11:30
5
5
5
sum:
Available
Work:
830
720
115%
2
5
15
15
5
5
15
15
5
5
15
15
5
5
15
15
5
5
15
15
sum:
Available
Work:
830
720
115%
sum:
Available
Work:
635
720
88%
Queuing for a server: Avg wait time in hours
It’s math—not luck!
96% Utilization
80% Utilization
Shift the curve:
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Follow the value!
Map the stream and remove the waste
Give staff time to engage patients
Leverage fungible staff substitutions:
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Lab/X-ray subs for ED staff!
Paramedic substitutes for RN
RN subs for Doctor
Hospitalist subs for ED doctor
Average patient collections
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Know the cost of a walkout
Know the value of a bed-hour
Do the math on LOS changes and staffing
What is the value of shorter LOS in nursing
cost?
• What is the value of increased physician
productivity?
The roving bottleneck server
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Triage
Doctor
RN
Pharmacy
CT or X-ray
• Read The Goal to understand bottlenecks.
Arrival curves
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Demand:capacity matching
By day of week and hour
Differential scheduling by day?
Nurse and doc must match!
How about housekeeping and transport and
CT servers?
D2D: Slice and dice it!
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By day
By doctor
By arrival nurse
By shift worked
No excuses
What do you get if you overdo D2D?
LOS
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By doctor
By nurse
By area
By shift
By disease state or resource utilized
What if you overdo LOS?
Patients per hour
• By doctor
• By shift
• By day of week
Is it low because of lack of patients?
Admission rate
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By doctor
By disease and by doctor
CHF
Chest pain
Abdominal pain
Why does it vary so much?
Utilization by doctor or by disease or both!
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Lab
CT
Morphine equivalents
Total pharmacy cost per patient
Admit
Obs
Total cost
Use the info to coach and ask the right questions!
Let the high performers teach the rest.
Radiology
• By CT groups:
– brain/C-spine
– Chest/belly w/IV only
• X-ray:
– Portable chest
– Others
• Study vs. reading on each of above
• By hour of day
CT, in particular
• A significant fraction of your patients are waiting
for a CT result
• CT rate often is in the neighborhood of admit
rate
• Cannot dispo until CT is done and read
• This key server requires management
• The radiologists probably won’t volunteer to
perform better (see demand:capacity chart).
The ED alone can rarely manage this process.
Time for pharmacy
• Med pick and delivery times
• Frequency of med send and what drugs
• Frequency of stockouts in ED
Beyond Core Measures
• Measure best care, not just the core measures
• “consensus committee” or some other way to
decide what good care looks like
• Wildly different than CMS deciding for you
• Easy examples:
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imaging rules for head and neck
completion of NIHSS for stroke
time to pain meds for fractures
sepsis care
The biggest miss: pay for satisfaction
• What does this incentivize?
• Why is it so fundamentally at odds with
“doctorhood”?
• How does it fit with our national pill problem?
• Do the people around you actually understand
percentiles and how that works?
• Does the hospital understand common cause
variation?
On Call: measure it if you bought it!
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Call back time?
ED physician satisfaction (particularly if paid)
Time to definitive care
Supply use for surgical cases
Measuring and reporting it is almost as good
as putting it in the contract, but without the
contention.
Readmissions vs. flow
• Managing readmissions is at odds with ED flow
• Is it easier to readmit than other options?
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Social work?
Inpatient doctor consult?
Ethics consult?
Palliative care?
Talk to the NH doctor?
• All take time and have limited resources!
• Providing resources will move the needle
Dashboard: goals and colors
• Conditional formatting works
• (S)He who controls the dashboard file has
considerable control!
• Much like control of the meeting agenda!
ED Balanced Scorecard
CATEGORY MEASURE
Volume
Contract Hours
CLINICAL
Total Admit Rate
Total CTs
% patients getting CT
Total PE Studies
PE Studies/Pt
Total Head CTs
Head CTs/patient
Abdominal X ray Use %
Lumbar Spine Radiograph Use %
Cost Per Case 2014
Narcotic Prescribing
Regular Use of TNCSMD
Emergency Medicine Core Group Skills
Blood Use
Type and Screen Total
Rate/Pt
Type and Cross
Rate/Pt
Documentation
Critical Care Rate (% of charts)
Total Undoc services for 2013 $
Rate of Undoc: $/pt vol
Quality progress notes w/ MDM?
Visits/hr Solo
RVU/Pt
RVU/Hr Solo
Overtime rate
Source
Typing WPM- www.typingtest.com
Door-to-doctor Year
% over 4 hours
Under 1 Hour Visits
Median LOS
AMA Rate
Raw Score Patient sat last 12 m
Last Hour Performance/Shift Change
Works to End of Shift
Tele Monitor Use on admits
Rate of ICU Admission
Citizenship Conference Attendance
White Coat Worn at Work (A, U, S, R, N)
Chart Review Participation
Meeting Attendance:
Patient Complaints-subjective
Committee, special projects, other work
Radar Factor--positive or negative
Nursing Relationships
Behave professionally?
Arrive on time and ready to work?
Efficiency
Scorecard goals
• Data
• Focus each doc on 1-3 items
• Rank performance compared to internal and
external benchmarks of high performers.
• Use color conditional formatting
“Physicians are quick to challenge performance data
and to identify methodological problems with them.
But the fact is that they are mesmerized by data
and cannot look away.”
- Dr. Thomas Lee: Turning Doctors Into Leaders,
Harvard Business Review, April 2010.
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