Quality Improvement & Patient Safety Section Newsletter, December 2011
|The Chair’s Letter - Quality Improvement & Patient Safety Section Newsletter, December 2011|
|Editor’s Note - Quality Improvement & Patient Safety Section Newsletter, December 2011|
|Board Liaison’s Note - Quality Improvement & Patient Safety Section Newsletter, December 2011|
|2011 Resident Award Recipients - Quality Improvement & Patient Safety Section Newsletter, December 2011|
|Annual Meeting - Quality Improvement & Patient Safety Section Newsletter, December 2011|
|The Psychology of Admitting Patients - Quality Improvement & Patient Safety Section Newsletter, December 2011|
|QIPS TIPS - Lady Macbeth, Do the Math - Quality Improvement & Patient Safety Section Newsletter, December 2011|
|Part 3- Manage for Engagement - Quality Improvement & Patient Safety Section Newsletter, December 2011|
|Resident and Young Physicians Section - Quality Improvement & Patient Safety Section Newsletter, December 2011|
|QIPS National Agency News Section - Quality Improvement & Patient Safety Section Newsletter, December 2011|
|In the News: Recent Quality and Safety Articles - Quality Improvement & Patient Safety Section Newsletter, December 2011|
The Chair’s Letter - Quality Improvement & Patient Safety Section Newsletter, December 2011
Heather L. Farley, MD
Assistant Chair, Department of Emergency Medicine
Christiana Care Health System, Newark, DE
Assistant Professor- Jefferson Medical College
As we begin a new year, it is important to reflect upon the goals of our section and communicate what we hope to accomplish in the upcoming months. The Quality Improvement and Patient Safety Section of ACEP (QIPS Section) is dedicated to improving the safety and quality of patient care on a local and national level. With the current focus on healthcare reform, expansion of quality reporting, and proposed healthcare cost-containment strategies, the ideas shared and work conducted within the QIPS section is timely, and vitally important to our specialty.
In addition to advocacy efforts, participation in QIPS offers members an invaluable opportunity to network with like-minded individuals, collaborate on projects of mutual interest, and advance the field of knowledge in quality and safety. Here is a taste of some of the projects QIPS has undertaken in the last 5 years (supported by section grants):
- White paper on the quality and safety implications of ED information system implementation (in progress)
- White paper on ED procedural safety (submitted for publication)
- Survey assessing the use of time outs in the ED
- Kelly JJ, Farley H, O'Cain C, Broida RI, Klauer K, Fuller DC, Meisl H, Phelan MP, Thallner E, Pines JM. A Survey of the Use of Time-Out Protocols in Emergency Medicine. Jt Comm J Qual Pat Saf. June 2011; 37:6: 285-288.
- White paper discussing ED patient hand-offs
- Cheung DS, Kelly JJ, Beach C, Berkeley RP, Bitterman RA, Broida RI, Dalsey WC, Farley HL, Fuller DC, Garvey DJ, Klauer KM, McCullough LB, Patterson ES, Pham JC, Phelan MP, Pines JM, Schenkel SM, Tomolo A, Turbiak TW, Vozenilek JA, Wears RL, White ML. Improving handoffs in the emergency department. Ann Emerg Med. 2010;55:171-180.
- Development and publication of an ED Quality and Patient Safety Curriculum
- Kelly JJ, Thallner E, Broida RI, Cheung DC, Meisly H, Hamedani AG, Klauer K, Welch SJ, Beach C. Emergency Medicine Quality Improvement and Patient Safety Curriculum. Acad Emerg Med. 2010; 17:e110–e129.
Over the next year, we hope to discover and implement new, innovative ways to engage our section members. We are excited to involve as many members as possible in section activities, including the following:
- Development of an improved, searchable, content-rich QIPS website
- Addition of a resident section to our quarterly newsletters
- Creation of a “toolbox” containing practical solutions and tools for various quality and safety issues that can be shared amongst members
- Initiation of quarterly “all-section” conference calls to allow open discussion regarding topics of interest to members
- Application for a 2012 ACEP Section Grant (topic to be determined)
We welcome your comments and suggestions!
Editor’s Note - Quality Improvement & Patient Safety Section Newsletter, December 2011
Christopher Beach, MD
Associate Professor of Emergency Medicine and Vice Chairman
Department of Emergency Medicine, Northwestern University
Northwestern Memorial Hospital, Chicago, Illinois
Fresh from another Scientific Assembly, the members of ACEP’s QIPS section are gearing up for another productive year. As reported by the QIPS Chair, Heather Farley, members of QIPS have contributed substantially to the quality and safety genre in past years. Notably, almost all of the authors on these manuscripts are current QIPS members. QIPS is a group of engaged, experienced and dynamic emergency physicians who continue to seek ways to make care safer and more effective. It is a pleasure to share insights and ideas with such a diverse and friendly group of clinicians, whether through our monthly conference calls or within projects, such as ACEP Grants. We encourage anyone who has an interest in quality and safety to join us, especially young physicians or EMRA members who are wondering what quality and safety is all about, or are looking for mentorship and advice.
In this edition, experts in quality and safety – Dickson Cheung, Shari Welch and Mark Jaben reveal valuable tools and insights. Once again, Helmut Meisl offers a list of recently published quality and safety citations for your interest. A new section begins in this edition entitled, “Resident and Young Physician Section” with an article by a resident physician at Northwestern University, Andrew Lee. He and co-authors, Michael Schmidt, MD and Eileen Brassil, RN describe a novel way of addressing ‘front-line’ operational initiatives, particularly the challenges of communicating effectively in an ED with an electronic medical record. We provide minutes from the annual QIPS meeting at SA, which was highlighted by Dr. Jay Schuur’s talk, “The Cost of Emergency Care: 2% or the Opportunity of Your Life to Lead.” A list of award winners from the first annual resident quality project competition and National Agency Updates are included. Finally, we are soliciting material for a new section called, “The Toolbox”. Material suitable for this section would include short descriptions of clinical practices, tricks-of –the-trade or operational processes that enhance patient care, improve quality and safety, or promote efficiency.
Again, we’d like to invite any interested EP’s to join our section. In particular, we are reaching out to members of ACEP’s Young Physician Section or EMRA members to contribute to our newsletter or join the QIPS section. QIPS members with decades of real-life experience in quality and safety are eager and happy to assist anyone interested in engaging themselves in this important component of emergency care practice and help you develop your leadership talents. Don’t be shy - join our active group and help us find ways to promote better emergency care. How can you do this?
- Email a QIPS member - Chris Beach, Heather Farley, Rich Griffey , or staff assistant Dainsworth Chambers with your question or inquiry.
- Submit a piece for “The Toolbox” – a short description of a clinical practice skill or operational process which improves quality, safety, efficiency or satisfaction.
- Residents and Junior Faculty
- Submit an article on a topic of interest or an area of your expertise which improves patient care or professional practice for the “Resident and Young Physician Section”.
- Submit a project for next year’s QIPS Resident Quality Award competition.
- Join a conference call – look for more details in coming newsletters or contact a QIPS member
We’d like to thank Dainsworth Chambers, our ACEP Quality and Federal Affairs Assistant for coordinating the newsletter and QIPS section activities. We hope you enjoy this installment of the QIPS Newsletter.
Board Liaison’s Note - Quality Improvement & Patient Safety Section Newsletter, December 2011
Jay Kaplan, M.D., FACEP
QIPS Board Liaison
Allow me to introduce myself. My name is Jay Kaplan and I am the ACEP Board of Directors liaison to the Quality Improvement and Patient Safety Section. Some of you may already be aware of ACEP leadership and others may not, so I thought it would be a good idea to provide some background for what we do as a Board to promote and safeguard your practice.
The Board of Directors provides day-to-day management and direction to ACEP and serves as its policymaking body. Board members are elected by the ACEP Council and serve three-year terms, with a limit of two consecutive terms, representing a wide variety of backgrounds and work experiences in emergency medicine. Some are academics, some hold administrative positions with physician practices, and some are full-time practicing staff physicians. All of the current twelve members of the Board continue to work clinically in the emergency department setting. Every section in ACEP is assigned a section liaison who serves as a resource for the section.
In the past year we have been very involved with advocacy and health care reform. While health care reform was passed in the Affordable Care Act of 2010, how the components of the legislation get implemented will be defined by the regulations that are now being written. We created the Emergency Medicine Action Fund and raised greater than $1 million to provide financial resources so that we can be actively involved in Washington to assure that we and our patients are well represented. It is quite clear that the old paradigm of “deliver care and you will get reimbursed” is being replaced by “deliver quality and you will be reimbursed.” And the “Quality” that I am referring to is being defined now in those regulations and by national organizations like the National Quality Forum and the Center for Medicare and Medicaid Services. Emergency Medicine must be at the table in the discussions regarding what quality emergency care is. Value-Based Purchasing is here to stay. We also have two new Task forces this year, the Delivery System Reform Task Force and the Transitions of Care Task Force. We will be working hard to stay on the leading edge.
At the same time that we as a board and organization are representing your interests nationally, I want to make certain that you feel supported in your clinical and educational pursuits. If there are issues which you feel that we as a Board need to explore and act upon, please let me know.
I also serve as the Board liaison for the Education Committee. We are in the process of planning the Scientific Assembly for 2012. I believe that we have outstanding faculty speaking on Quality subjects. If any section members (who are not already presenting at ACEP meetings) wish to be national faculty for ACEP, I would welcome your expressions of interest.
If there is anything that I can do to assist you, please contact me .
2011 Resident Award Recipients - Quality Improvement & Patient Safety Section Newsletter, December 2011
Christian Ross, MD. Indiana University
Improving Safety of Patient Handoff in the ED: An Interactive Method of End-of-Shift Changeover
Damien Kinzler, DO. Albert Einstein Medical Center
Quantifying the Time-to Loop Closure for ED Radiology Discrepancies
Jonathan Heidt, MD. Washington University School of Medicine
Transition of Care in the Emergency Department
Jenny Chen, MD. Naval Medical Center San Diego
The Effect of Emergency Department On Site Simulation Based Resuscitation Training On Team Communication
Trushar Naik, MD, MBA. Kings County Hospital
A Structured Approach to Transforming a Large Public Emergency Department via Lean Methodologies
Annual Meeting - Quality Improvement & Patient Safety Section Newsletter, December 2011
Annual Meeting Agenda
- Welcome From the Chair
- Councillors’ Report
- Incoming Chair Remarks
- Educational Program - Dr. Jeremiah Schuur, MD, MHS “The Cost of Emergency Care: 2% or the Opportunity of Your Life to Lead”
- Resident Award Presentations
- ED Quality Director Survey Highlights
Welcome from the Chair. Dr. Fuller opened the annual meeting by welcoming section members and having each member give a brief introduction.
Councillors’ Report. Handout
Elections. Drs. Farley and Fuller conducted elections. Results are as follows:
Heather Farley: Chair
Chris Beach: Newsletter Editor
Drew Fuller: Website Editor
Incoming Chairs Remarks. Dr. Farley thanked the section for electing her as chair. She recognized a number of section members and staff for their ongoing support and contributions.
Educational Program. Dr. Schuur made a presentation entitled, “The Cost of Emergency Care: 2% or the Opportunity of Your Life to Lead.” The presentation was based on a paper authored by Dr. Schuur, which was recently published in ……..The presentation allowed audience members to participate in a series of questions about their opinions on a host of topics, including health care reform, cost drivers and decision-making processes used by EM physicians. The presentation provoked a lot of thought and questions from the audience.
Resident Award Presentations. Christian Ross, Damien Kinzler, and Jonathan Heidt (three out of five of the resident award recipients) were on hand to receive their awards and give a brief presentation on their project. Dr. Ross and Dr. Heidt gave presentations that explored transition of care in the emergency department. Dr. Kinzler’s presentation explored Quantifying the Time-to Loop Closure for ED Radiology Discrepancies. Dr. Fuller noted that each presentation was selected because of its importance to improving emergency care and patient safety.
ED Quality Director Survey Updates. The QD survey is making progress. Drs. Thallner, Hamedani, Farley and Griffey are soliciting more responses.
There being no further business, Dr. Farley and Dr. Fuller adjourned the meeting at 3:00 p.m.
QIPS Past Chairs (left to right) Helmut Meisl, MD; Dickson Cheung, MD; ACEP
Board Rep Paul Kivela, MD; Sue Nedza, MD; Drew Fuller, MD; Bob Broida, MD
Incoming Chair Heather Farley, MD presenting Certificate of Appreciation to
outgoing Chair Drew Fuller, MD
Chair-Elect Rich Griffey, MD, and Immediate Past Chair Drew Fuller, MD, receive
award for ACEP Newsletter of Distinction
The Psychology of Admitting Patients - Quality Improvement & Patient Safety Section Newsletter, December 2011
Dickson Cheung, MD, MBA, MPH
It is one of emergency medicine’s dirty little secrets. That is, there is no objective standard upon which certain patients get admitted to the hospital and others gets discharged. Sepsis stays and ankle sprains go home. But patients with conditions in between these two extremes are up for grabs: chest pain, syncope, atrial fibrillation, gastroenteritis, GI bleeds, pneumonia, cellulitis, DVT/PE, etc. The decision to admit is left up to the whim of the individual physician with little guidance from the healthcare system.
Three years ago, Arjun Venkatesh (another QIPS member) and I participated on an AHRQ-funded project to vet Prevention Quality Indicators (PQIs). They are a group of quality measures aimed at improving the care of “ambulatory-sensitive” conditions (e.g. UTI, asthma, etc); in other words, conditions that if managed appropriately could be theoretically kept from an inpatient admission. Thus, the outcome variable for most of these proposed measures was admission to the hospital (read: failure of the system). One of the most surprising assumptions of the panel was that once patients triggered an ED visit, there was a uniform approach to the decision making of repatriating these patients back to the outpatient world. Nothing could be further from the truth.
I have had the opportunity to work in many diverse settings: in posh downtown hospitals, in wealthy bedroom communities, in seedy county hospitals, in tertiary care university hospitals, in west coast managed care hospitals. I have no data to prove this [yet], but I can tell you that the threshold whether or not to admit a patient varies widely among practice settings. The bar to admit a patient in the Kaiser system is vastly different than at my current suburban private hospital. Not only who gets admitted but where they get admitted. At the county hospital where I used to work, you literally had to be either intubated or on vasopressors to gain access to the ICU. Not so much so at other hospitals.
More disturbingly, even within the same setting, there is wide variation in practice. I’m sure within each of your physician groups, there are docs who are sieves and those who are walls. There are EM physicians who operate with the working assumption that every patient needs to be admitted (until proven they can handle discharge) and those that view that all patients should be given a chance at discharge. My own admission practices admittedly [no pun intended] vary from practice setting to practice setting, from the time to the end of my shift, my present patient load, day of the week and time of the day.
What goes through the mind of an emergency physician whether or not to admit a patient? Why the wide practice variation? I’ll elaborate on four possible reasons and why our individual tolerances for each can explain some of the variation.
The first is expediency. In my weaker moments, I often choose the road easier travelled. It may be because the patient just doesn’t want to be discharged (or, admitted). Some may call it a patient-centered approach or a shared-decision making model. But the truth is, sometimes it is just the path of least resistance. Examples: the patient with a DVT that is going to require lovenox teaching and INR testing, the diabetic patient with facial cellulitis that will need multiple doses of IV antibiotics. If it is at the end of the shift and the patient with biliary colic is requiring a fourth dose of narcotics, I am more likely to admit the patient than to burden the oncoming doc. As the receiving doc, I am sometimes racked with guilt for hoping that an established patient “on the fence” will take a turn for the worse just so the disposition is clear. Other times, I quietly hope for a significant lab abnormality that will justify admission. Closure, any closure, is preferable than a loose end. Admission, discharge, AMA, death. Any of these are seemingly better than a protracted ED course when you are in the trenches.
Another piece of psychology that factors into the admission decision is the fear of retribution. Let’s face it, we’re afraid to be sued or scrutinized. We know that the 32 year old man in bed #11 we’re admitting for chest pain has a lower chance of presenting with ACS than the Chicago Cubs do of winning the pennant. But, if you work enough shifts, for enough years… you will be unlucky enough one day to fall on the landmine of an atypically young patient that suffers a heart attack. It is just the odds of playing in the game of ED roulette. Just like one of these centuries, the Cubs WILL win the World Series. But we shouldn’t be wasting our money putting down bets that they are going to win THIS year. That would be foolish. In order for ED docs to change their practice, there must be some legal protection for doing the most reasonable thing for most patients. But even if there is malpractice reform (and that is a BIG IF), I’m not sure ED docs will be so quick to change. For decades, ED physicians have been trained to practice defensively. Even if the rules change, this will be a hard habit to break. This fear of the worst case scenario is deeply ingrained in our psyche.
A related concern is the fear of blame for a patient who returns to the ED, even if no harm results. Just as hospitalists are judged by the number of readmissions they accrue, ED physicians are monitored by the number of return ED visits. Even though return visits are probably not valid as a quality measure, hospitals still use them. [See article by another QIPS member: Pham JC, Seventy-two-hour Returns May Not Be a Good Indicator of Safety in the Emergency Department: A National Study. Acad Emerg Med 2011]. Many EDs automatically flag patients who return unplanned for review. To change practice, we will need to accept that a certain percentage of patients may bounce back. If there was no harm, there should be no blame. These patients are just outliers in the distribution. Instead of expecting every patient will fly on discharge and admitting everyone that has even a remote chance of returning, we should admit fewer patients with the understanding that some may boomerang.
Finally, there is the matter of patient safety. Apart from the whole legal risk issue, EM physicians feel a genuine sense of responsibility for the individual patient in front of them and to provide the best care possible. Even if it is at great cost to the system. So if we are unsure that our patient can afford the prescription, or schedule that outpatient stress test, or get transportation back to the hospital if needed, we err on the caution and admit the patient. Oftentimes, there are no other suitable options. We know that if we admit the patient at least then, they’ll get what they need in the short term. The problem is that while the patient gets what they need (e.g. serial IV antibiotics), they also get what they don’t need (e.g. 24 nursing care, expensive bed in prime real estate, frequent rounds by highly paid professionals, three square meals a day, all their existing medications delivered at inflated costs).
So, are there any answers to decrease variation in admitting practices and decrease unnecessary admissions? I’ll offer a few in hopes of starting a discussion on other potential solutions. First, we need to start to establish some consistent standard for admission. These should be developed with relevant stakeholders including hospitalists, ED physicians, PCPs, patients, hospitals and payors. Yes, there are Interqual and Milliman criteria to decide which admitted patients will get reimbursed. But instead of such a blunt guillotine, I am suggesting is that we base our decision on clinical and patient-based criteria that aim to move more patients safely into the outpatient world. In other words, let’s figure out what a patient “needs” to be a successfully managed as an outpatient. Since outpatient resources within healthcare systems (e.g. availability of durable medical equipment and home visits) and other special abilities within the ED (e.g. observation units) are likely to influence the safety and feasibility of outpatient management, these negotiations are probably best conducted locally. Certain medical conditions are prime targets for outpatient patient management [see article by QIPS member: Schurr JD, Critical Pathways for Post–Emergency Outpatient Diagnosis and Treatment: Tools to Improve the Value of Emergency Care. Acad Emerg Med 2011]. Second, healthcare systems need to provide more resilient options for outpatient management e.g. extended office hours, access to diagnostic testing, available pharmacies, etc. Without these alternatives, ED physicians will default to the easiest option which is admission to the hospital.
We can no longer afford to live in ED silos. As the new ACEP president Dr. Seaberg said in his opening address to the Council, “Emergency physicians must consider stepping out of our perceived comfort zone and perception of only providing acute care.” We will need to integrate ourselves better with respect to the entire cycle of patient care, expanding our role beyond simple gatekeepers of hospital beds; but rather, involve ourselves in the upstream and downstream care of our patients. I still recall the trauma docs that I trained with in residency who impressed upon me that their role in the healthcare system was not just to patch up trauma victims after they were shot or stabbed. They took it upon themselves to not only become experts in the OR and in the ICU but also as advocates of trauma prevention programs, rehabilitation services and related public policies. Similarly, we need to view ourselves as more than just docs who “treat and street” patients or just conduits to hospital beds. We also need to be masters of follow-up of discharged patients and partners with hospitalists in expediting patient stays and improving outcomes in the hospital.
The decision to admit a patient from the ED is currently the single most costly decision we make on a routine basis. There will be growing pressures to admit fewer patients in the future. Making the right decision won’t be easy [see Asplin BR, Value-Based Purchasing and Hospital Admissions: Doing the Right Thing Isn’t Easy. Ann of Emerg Med 2011]. But we, as emergency physicians, need to figure out how to responsibly and innovatively provide better care for our patients at lower costs. And that is going to take a new mindset about how we view hospital admissions, addressing our own biases and investing in new roles if we are to have a future in healthcare reform.
QIPS TIPS - Lady Macbeth, Do the Math - Quality Improvement & Patient Safety Section Newsletter, December 2011
Shari Welch, MD, FACEP
Intermountain Institute for Health Care Delivery Research
Salt Lake City, UT
Lady Macbeth had it right: Wash your hands! Over and over and over…. She was obsessed with it. Physicians and healthcare workers should be too. On any given day patients will suffer 1.4 million healthcare-acquired infections worldwide. And the evidence is uncontestable - hand washing prevents the transmission of infectious diseases in healthcare settings. Both the World Health Organization (WHO) and the Centers for Disease Control (CDC) agree that proper hand hygiene is the single most important, simplest, and least expensive means of preventing healthcare-acquired infections. In addition, it is equally important in combating transmission of multidrug-resistant pathogens. And for those still objecting to the evidence, a recent study has correlated hand washing efforts with the ultimate outcome measure – survival in the ICU. Researchers at the University of North Carolina found that an initiative to reduce bloodstream infections in the pediatric ICU, with emphasis on hand washing in particular, reduced the length of stay for small patients in the ICU, reduced the cost of a stay, and reduced the mortality rate.
Even with all the evidence, though, getting staff to participate in robust hand washing efforts has been a difficult and largely unsuccessful endeavor. Some improvement has been seen when alcohol rub dispensers are placed strategically in a clinical unit. This might be because it takes less time to “wash” with rub, which can be done as providers walk from room to room, than to stand at a sink and navigate both soap and towel dispensers. Design research has something to add; investigators have found that placing sinks at an angle to the patient’s bed facilitates hand washing because they don’t require the provider to turn his back on the patient or family members. Other efforts, like signs at the head of the bed, more sinks strategically located, real-time feedback, and continuous tracking, all help to improve hand washing compliance.
In spite of all this, it is still common for baseline data to show physician and staff hand washing compliance as low as 35 to 50%. The problem may relate to the “burden” of hand washing on workflow in the clinical setting. Think about it for a minute and do the math. Current recommendations call for the cleansing of hands both before and after seeing a patient. (Not a bad plan with what we know about contaminated surfaces when a patient is colonized with MRSA for example). A physician in the ED will see roughly 2 patients an hour. The ED visit will involve at minimum a visit with the patient on arrival and a visit prior to discharge, and for many complaints there will be more patient assessments in between. But even assuming just two patient encounters at the bedside and washing hands before and after each visit, the ED physician will be required to wash his hands an impossible 64 times in an 8 hour shift!! This means washing hands approximately every 7 minutes for 8 hours straight! Is it realistic, doable, sustainable???
Copper surfaces have been shown to retard bacterial growth. At one hour, MRSA-contaminated surfaces had zero live bacterial counts on a copper surface. Apparently, dry copper causes damage to cell membranes within minutes. BTW, it does not cause mutation rates or DNA damage. Copper is almost as effective on viruses; at one hour after contact with copper only 75% of influenza A virus is viable. We are just beginning to understand the antimicrobial properties of copper, but the implications for the building design in healthcare are substantial.
What if healthcare providers could wash their hands BEFORE touching a patient, and let the copper do the rest? There might then be more time for physicians and other healthcare providers to do the work that needs doing. Lady MacBeth had it right, but we in medicine need to do the math. There may be innovations afoot that would reduce the required hand washing by half. These innovations will lead to even better medicine!
Part 3- Manage for Engagement - Quality Improvement & Patient Safety Section Newsletter, December 2011
Mark Jaben, MD
In parts 1 and 2, I tried to define what engagement really requires, and how many of the current metrics are counterproductive to creating an atmosphere conducive for engagement.
To make it better for patients, we must make it better for those taking care of the patients.
Working at a comfortable pace provides staff with the best opportunity to do their work well.
We have all experienced shifts in the ED when everything goes smoothly. The patients have the appropriate care delivered and their concerns addressed. The ancillary services are consistent and timely. Admitted patients move expeditiously out of the department. At the end of the shift, staff have a low ‘foot pain score’ and feel good about the day’s work. This is the comfortable capacity of your ED.
When more is required, individuals can and do increase their individual work pace to match the increased demand by taking productive shortcuts. But certain things have limits. For instance, there may be only one hospitalist to do admissions, or one ambulance available for transfers, and the same amount of computer work remains to be done. Beyond a certain point, increasing the pace only results in counterproductive shortcuts, increased mistakes, and increase stress. Overload has occurred. The aim with Lean practices is to increase this comfortable capacity level, but once overload is identified, to initiate a defined process returning the department to its comfortable level as quickly as possible.
Fortunately, every ED already has in place a clearly visible, real time gauge of its condition. An empty waiting room indicates that the department is keeping up with demand. In most cases, this easily observed indicator demonstrates that the comfortable capacity is way less than you think it ought to be. A full waiting room indicates there are significant backlogs downstream in the process. By this point, the situation is way out of control. A better sign would indicate when impending overload is possible, so steps could be taken to prevent the overload from occurring, or at least recognize it early enough to be able to get the department back to its comfortable capacity more quickly. A possible sign might be when any patient has to be placed in the waiting room after triage, or perhaps, when 80% of treatment spaces are occupied. Tracking patient dispositions hour by hour, an important clue when arrivals are outpacing departures, might be an even better metric.
These signs should generate efforts to create a space for the next patient to be brought into the treatment area by determining who is ready for disposition, what is preventing disposition, or who can be moved on to their next step in process on the way to disposition. Is there a backup due to lab or radiology studies, a particular nurse or doctor with more to do than they can comfortably get done in the time frame required, or admitted patients waiting to be moved into the hospital? What if several of these backlogs are occurring at the same time? What if there is also a backup due to a sudden influx of patients, making it necessary temporarily to increase the capacity of triage, an important safety and quality mechanism to be sure nobody requiring emergent treatment is overlooked. Who will be tracking this, and what will be done to help each step get caught up? A clearly visible, real time sign to indicate impending overload alerts staff to focus on the circumstances creating the backlog and determine its cause and effect right then and there. Defining the available options ahead of time and giving staff the latitude to craft the appropriate response produces a more effectively directed plan in returning the department to a more comfortable condition.
This focus on downstream processes to free up capacity to see the next patient illustrates the key concept that flow is generated at the backend. This guides individuals on where to prioritize their work at any given time, enabling them to see how their work contributes to decreasing the LOS, which, in turn, increases the capacity of the department to do more. LOS can be used as a valuable sign to indicate impending overload if measured real time, or as a helpful daily gauge to learn if your department ran at its comfortable capacity the day before. When measured for each of the three kinds of patients, straightforward, complicated and complex, or for separate areas in the ED, like a fast track or holding area, it can help to identify where the backlogs actually occur.
If the department is experiencing overload daily, then the system is not adequate and needs attention to its design. Each process in the system is made up of a sequence of steps, each with a set of tasks, each interdependent with the preceding and following steps. The tool of Value Stream Mapping can be helpful to identify where problem solving should be directed, and focus improvement efforts in the most productive ways.
Patients discharged per hour for the ED as a whole, rather than seen per hour by an individual, is a better metric for engaging individuals because it focuses attention first on the process of care, overwhelmingly the most common source of underperformance, contrary to popular belief. If a particular provider seems to be associated with the department not keeping up with demand (i.e., patients discharged per hour is consistently lower during one provider’s shifts), rather than hold this provider ‘accountable,’ 1) identify the difficulties or obstacles during that provider’s work time and 2) learn from other providers how the department deals with these when they occur during their shifts. This shared learning creates a more palatable atmosphere for someone to be interested in critically evaluating their individual work, an essential condition for engagement.
Managing for engagement means asking the right questions, identifying the crucial obstacles, committing to dig deeply to discover the real problem , and working to train, support, and mentor front line staff to do their work well, both individually and collectively. By focusing on these processes, it is possible to create a work environment where people believe they can be successful in their work. But it is only through a commitment to solve the problems through collaboration and shared responsibility that will enable us to learn what it really will take to get results in serving the healthcare needs of patients and communities.
In the final installment, we’ll look at some specific steps to promote engagement in improving the flow for individuals, as well as the department, and in the closing epilogue, why the words we use really matter for engagement.
Resident and Young Physicians Section - Quality Improvement & Patient Safety Section Newsletter, December 2011
An Academic Medical Director’s New ‘BFF’: The Resident & Nurse Operations Task-Force
Andrew Lee, MD – Resident Physician, Dept of Emergency Medicine
Michael J. Schmidt, M.D. – Medical Director, Dept of Emergency Medicine
Eileen Brassil, RN, BSN, CEN – Clinical Coordinator, Dept of Emergency Medicine
Northwestern Memorial Hospital, Chicago, Illinois
An Unexpected Consequence
Implementation of healthcare information technology (HIT) has been recommended as a way to improve healthcare quality, improve patient safety, and reduce healthcare costs. (1) Unexpected consequences, unanticipated sources of error, and even patient harm have been described after implementation. (2,3) Like many other institutions throughout the country, our hospital and emergency department converted to a full electronic system. While certain aspects of information transfer have improved, such as making ED notes available to both outpatient and inpatient providers, others may have worsened. One unexpected consequence of the implementation of our electronic system has been the erosion of direct communication between physicians and nurses and the team-based care model. Nursing and physician communication has been drastically altered because many patient care tasks can now be performed without direct verbal communication - the stroke of a key, in many instances, has eliminated the need to discuss, negotiate and inform. Physicians no longer have to find a paper chart previously kept near the nurse, which often facilitated discussion regarding specific patient care plans. Nurses rarely need to engage the doctors to receive orders. Moving patients within the emergency department, transferring patients to the floor, and discharging patients are all communicated via an electronic tracking board. Even alerting the team to a critical patient is occasionally performed through the electronic patient acuity flag. And finally, nurses and doctors have unknowingly segregated themselves to computer workstations in separate areas of the emergency department, creating a physical barrier. All of these changes have led to a noticeable decrease in direct communication between care providers, sometimes leading to frustration on the part of physicians, nurses, consultants, ancillary staff AND patients.
Recognition of the issues
Every fall the residency holds a retreat designed to review the state of the residency, identify areas in need of improvement and to cultivate improvement ideas. Prior to the retreat, the hospital had been above full capacity for several weeks, and the emergency department had been experiencing record-breaking inpatient holding times. This strain on operations made issues related to communication even more evident. These culminated in growing frustrations and the search for solutions. While somewhat difficult to address, the timing of it all led to a retreat that was dominated by the topics of doctor-nurse communication and patient flow.
Key observations were made, including an overall lack of doctor-nurse communication, poor understanding of each group’s processes and hierarchal structure, resident frustration over perceived lack of control regarding the placement of patients, and a subtle downward trend in professional morale. Many interesting ideas and opinions were shared, but only the physician side was represented during this retreat. Following the retreat, a small group of residents attended the ED Operations Committee meeting, which includes the medical director and his team, nursing director and nurse managers. The intent was to address communication within the department, particularly among the “front-line” care providers, and develop a means to gather opinions of all members of the ED team. Not surprisingly we found the goal of providing the best emergency care had always been the inherent, shared mutual goal amongst all members, but that the solutions to achieve this consistently would not be easy.
Formation of Resident- Nurse Operations Task-Force
It was clear from our preliminary discussions that more work was needed to both better understand each other’s professional responsibilities and to develop process changes that benefited the entire ED, and, most importantly our patients. These thoughts led to the formation of a resident-nursing operations task-force. The main goals of the group are to improve communication throughout the ED, foster better understanding of the roles and strengths of each provider, and to develop “front-line” solutions to common problems. This task-force is a subcommittee of the ED Operations Committee. Participation is open to all within the department, with the hope of attracting all levels of residents and a wide variety of nurses, in order to gain the full perspective of challenges facing the ED. While the group coordinates with and reports to ED Operations Leadership, it has the freedom to pursue ideas and solutions in a grassroots fashion.
Two senior residents and a Charge Nurse (Clinical Coordinator) lead the task-force, but it is open to all, and any interested resident or nurse may attend the monthly meetings. The group’s initial meeting (attended by 7 residents and 5 nurses) was focused on improving communication within the department. It was felt that even small improvements in communication between the groups could enhance patient care, morale and teamwork. Several areas were identified for improvement, one being the time following physician sign-out. Unbeknownst to the physicians, bedside nurses were unclear whom to refer questions following sign-out. Inaccuracies on the tracking board (oncoming physicians weren’t electronically signing up for patients already in care) and an incomplete understanding of the hierarchical physician structure by nurses were the causes. Two simple fixes were enacted. First, a simple diagram was created for the nursing group to help them gain a better understanding of physician sign-out practices and staffing structure. Secondly, residents were encouraged to sign up for old patients on the tracking board once the outgoing team had departed. The work group is currently trialing nurse-doctor huddles following sign-out so that patient care needs, staffing, and inpatient bed assignment delays can be reviewed. Face sheets with all of the nurses and residents (including names and photos) are being created so that everyone can more easily identify one another. Importantly, dissemination of such basic information in a large department had been a challenge. In this short time we have noted that engagement by ‘front-line’ physicians and nurses in this task force has improved information dissemination both formally, by email and paper, and, even more valuably, informally, through hallway discussion and the like. While these ideas are fairly simple, they require buy-in and reinforcement to achieve success.
Goals for the future
Our department, like many other emergency departments across the country, is in a constant state of self-improvement. While this is a positive attribute overall, it can also lead to a feeling of repetitive workflow and process changes, which can sometimes be a hindrance to success and sustainability. Through this group, we hope to bridge the gap between concepts and care providers. We envision the task-force as having a role in both creating and vetting some of the operational changes in the department, prior to full implementation. This task force will also allow interested residents and nurses to gain exposure to leadership roles and the challenges of operations management early in their careers. In an effort to boost teamwork and improve communication, we are creating a joint resident-nurse newsletter to announce not only work-specific information but to also introduce new hires, recognize achievements and honors, and share personal news such as birth announcements.
We believe our resident-nurse operations task-force will add value to the work environment by increasing the communication between nurses and physicians and improving teamwork, thus leading to enhanced patient care. We hope to evoke a sense of common purpose from the ground-up to rebuild the kind of team-based culture required in any high performing emergency department.
- Health IT and Patient Safety: Building Safer Systems for Better Care. IOM. 8 Nov 2011. National Academies Press.
- Han, Y. Y., Carcillo, J. A., Venkataraman, S. T., Clark, R. S., Watson, R. S., Nguyen, T. C., Bayir, H., et al., Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system, Pediatrics, 2005, 116(6):1506-1512.
- Safely implementing health information and converging technologies. JHACO. Sentinel Event Alert. Issue 42, Dec 11, 2008.http://www.jointcommission.org/sentinel_event_alert_issue_42_safely_implementing_health_information_and_converging_technologies/
QIPS National Agency News Section - Quality Improvement & Patient Safety Section Newsletter, December 2011
There is growing concern related to the overuse of various treatments, procedures, and tests in health care. The Joint Commission defines overuse as the use of a health service in circumstances where the likelihood of benefit is negligible and, therefore, the patient faces only the risk of harm. Seen from this perspective, overuse is a safety and quality problem. Additionally, research has demonstrated overuse occurs with frequency in the United States.
To address this serious safety and quality problem, The Joint Commission is proposing a new National Patient Safety Goal (NPSG) on the topic of overuse and is seeking input from the field.
Author: Diane Pinakiewicz, President NPSF
In 2009, the Lucian Leape Institute published a paper outlining a number of transforming concepts that are necessary to bring significant and lasting improvements in patient safety. Since then, the Institute has organized a series of roundtable discussions with expert panels to map a path to improvement. Following are some of the transforming concepts that have been identified to date:
- Medical Education Reform
- Care Integration
- Consumer Engagement
- Joy and Meaning in work and healthcare workforce safety
In the News: Recent Quality and Safety Articles - Quality Improvement & Patient Safety Section Newsletter, December 2011
Helmut Meisl, MD, FACEP
Quality Improvement Director
Good Samaritan Hospital
San Jose, California
Health IT and Patient Safety: Building Safer Systems for Better Care.
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