Join Section

Quality Improvement & Patient Safety Section Newsletter - June 2012

circle_arrowThe Chair’s Letter - Quality Improvement & Patient Safety Section Newsletter, June 2012
circle_arrowEditor’s Note - Quality Improvement & Patient Safety Section Newsletter, June 2012
circle_arrowThe Engagement Trilogy, Part 4-Engagement on the Front Line - Quality Improvement & Patient Safety Section Newsletter, June 2012
circle_arrowBenchmarking: So You Think You Are Good, Compared to What? - Quality Improvement & Patient Safety Section Newsletter, June 2012
circle_arrowResidents' Section: Care at Arrival - Quality Improvement & Patient Safety Section Newsletter, June 2012
circle_arrowEMPSF Emergency Care Patient Safety Summit - Quality Improvement & Patient Safety Section Newsletter, June 2012
circle_arrowQIPS TIPS: Sentinel Events in Healthcare: How to Respond - Quality Improvement & Patient Safety Section Newsletter, June 2012
circle_arrowQIPS Resident Quality Award - Quality Improvement & Patient Safety Section Newsletter, June 2012
circle_arrowQuality and Safety Articles - Quality Improvement & Patient Safety Section Newsletter, June 2012

The Chair’s Letter - Quality Improvement & Patient Safety Section Newsletter, June 2012

Heather L. Farley, MD
Assistant Chair, Department of Emergency Medicine
Christiana Care Health System, Newark, DE
Assistant Professor- Jefferson Medical College

Monitoring Your Metrics 

Heather FarleyPicture this:  You are working as the medical director for a mid-sized ED, and have been getting flak from hospital administration regarding your ED’s fast-track length of stay.  You decide to convene a workgroup to address the problem.  You are smart about it—you create a coalition of individuals with enough power to lead the change effort, including front-line staff.  Your team does their homework, performing direct observation of the current process, creating process flow maps, and identifying areas of waste (they have all drunk the LEAN kool-aid of course!).  A vision for change is created and communicated, and rapid cycle testing is performed to create the best possible standard work.  You invest heavily in education and communication during implementation of the new process, carefully monitoring your identified measures of success.  You (and your hospital administrators) are thrilled to observe a 70% reduction in your fast-track length of stay, and an impressive surge in patient satisfaction. 

After a few months of close monitoring, you feel confident that the new fast track process has reached steady state.  Your attention has now been shifted to responding to complaints about the door-to-doctor times for your ESI 3 patients.  Six months into your newest project, you have a rare free moment and decide to check on the latest fast-track length-of stay numbers.  You are horrified to discover that the median length of stay has increased significantly—hovering only slightly below your baseline numbers before your big change effort!   Breaking into a cold sweat, you hurry down to the fast-track to see what’s going on.  You are shocked to observe that staff have reverted back to the old way of doing things, and the agreed upon standard work is inconsistently being followed.  What happened?!?

Unfortunately, this scenario is fairly common.  A tremendous amount of effort and time is invested in a change process and early wins are enjoyed.  However, once the project has been deemed “a success”, attention is diverted to another pressing problem, and interest in the original project begins to wane. As a result, backsliding is almost inevitable.  New processes do not magically maintain themselves! As Kotter states in Leading Change, “The consequences of a mistake here can be extremely serious.  Whenever you let up before the job is done, critical momentum can be lost and regression may follow.  Until changed practices attain a new equilibrium and have been driven into the culture, they can be very fragile.  Three years of work can come undone with remarkable speed (1). ”

Why does this happen? Culture is a powerful influence.  It takes time for new approaches to be incorporated into the culture of your organization.  Staff must clearly see the connection between the new expected actions and the improved metrics being touted. In the meantime, components of the existing culture may drive them back to old way of doing things.  As a change leader, you must protect your new process during (and beyond) this fragile period.  What mechanisms do you have in place to accomplish this? 

One essential component of maintaining success after implementation of a new process is real time monitoring of pertinent metrics.  As suggested by Langley in The Improvement Guide, “Measurement provides a source of learning during implementation and a method of maintenance after implementation.  Some of the measurements developed and used in testing and implementation cycles should be considered for permanent use after implementation (2). ” Such diligent monitoring enables change leaders to detect backsliding early, and intervene in real time.  Providing real-time feedback to providers (whether positive or negative) is more meaningful and effective, and sends a message that leadership cares about the continued success of the project.  Not only should the target metrics be monitored frequently, but other drivers affecting the process should also be monitored (staffing constraints, boarding hours, etc).  To be most effective, the following components of metrics monitoring should be considered:

  1. Graphical displays of process-specific metrics pushed to ED leadership on a daily basis, usually via email. (i.e., the previous 24 hr median fast track length of stay, pts/hr seen through the process, ESI 4/5 LWOTs vs. goals).
  2. Continuously refreshed dashboard displaying a snapshot of current ED flow which can be viewed at any time.  Such dashboards enable instant understanding of the status of the major factors influencing ED operations (see example below).
  3. Process-specific dashboards for provider use.  For example, the current length-of-stay and door to doctor time of each patient in the fast-track process can be prominently displayed on a workstation in the clinical area.  Colors can be utilized to signal that the LOS or DTD time for a particular patient has exceeded the goal.   To be effective, these dashboards must display metrics the provider has immediate control over, be specific to the target work area, and easy to interpret at a glance.
  4. Periodic high level analysis to reexamine the goals of the process, determine if additional resources or expansion is needed, and discuss how the process fits in with the strategic vision of the organization.

The importance of monitoring and maintenance of a newly implemented process improvement project cannot be overstated.  With some creative thinking, and support from your friendly neighborhood IT professional, you can ensure that the investment of time and effort you have made in your change effort will pay dividends for years to come.  Good luck!

  1. Kotter, JP(1996). Leading Change (1st ed.). Boston, MA: Harvard Business School Press
  2. Langley, JL (1996). The Improvement Guide (1st ed.). San Francisco, CA: Jossey-Bass.

Editor’s Note - Quality Improvement & Patient Safety Section Newsletter, June 2012

Christopher Beach, MD
Associate Professor of Emergency Medicine and Vice Chairman
Department of Emergency Medicine, Northwestern University
Northwestern Memorial Hospital, Chicago, Illinois

christopherbeachIn this edition of the Quality Improvement & Patient Safety (QIPS) Newsletter we include a number of relevant issues facing ED quality and safety leaders.  Heather Farley, Chair of QIPS discusses the challenges of operational change and the day-to-day efforts required to improve efficiency and quality.  Once improvements have been ingrained in the culture of an organization, metrics of success can be benchmarked against other facilities.  Dickson Cheung, past QIPS Chair provides an overview and witty analysis of benchmarking in healthcare.  His insights offer the readers a well-rounded perspective on this month’s “hot topic.”

Dr. Mark Jaben provides his fourth contribution in his self-titled “Engagement Trilogy.”  Yes, the play on words is deliberate and his comments in this fourth piece continues to engage readers on how to improve care, while boosting efficiency.  He illustrates the importance of creating a dynamic and autonomous work environment dictated by the decisions of front-line care providers.  His article fits well with the Resident Section contribution by PGY3 EM resident Shelby Kaplan, who describes an initiative to improve the triage process.  Dr. Kaplan provides a brief overview of literature on the triage process and illustrates how managers promote autonomous and effective working practices by front-line care providers in triage to get patients care as rapidly as possible.

As always, Shari Welch presents another QIPS TIPS.  Her discussion of Sentinel Events and how to manage them is a valuable summary of this important patient safety management skill.  A follow-up to this in the September newsletter will discuss Crisis Management Plans.  A summary of this year’s Emergency Medicine Patient Safety Summit is included by Executive Director Diane Vass. Lastly, Helmut Meisl shares “What’s New?” in the quality and safety literature. 

We hope the readership finds the variety of topics discussed useful to improving quality and safety in their Emergency Departments.  As always we invite any reader to contribute to our Newsletter.  If you are challenged with a solution regarding a quality or safety problem, others are likely to be as well.  If you have worked through novel fixes to these same problems we want to hear about them.  The strength of QIPS comes from its members who openly share their experiences, challenges and insights to the quality and safety issues we all face.  Please consider contributing to future editions of the QIPS Newsletter.

Christopher Beach, MD

The Engagement Trilogy, Part 4-Engagement on the Front Line - Quality Improvement & Patient Safety Section Newsletter, June 2012

Mark Jaben , MD 

markjabenOrganizations need individuals willing to invest themselves.  This engagement creates the foundation for learning how to get results that actually work in your unique circumstances. This has been the subject of this series: what engagement actually means and what it requires (part 1), how our best intentions to date might be counterproductive to achieving engagement (part 2), and how better measurements might promote people’s willingness to be engaged (part 3).

In this installment, let's consider how we might translate engagement into some specific steps that result in better ED performance and a better experience for those who work there.  

Recall from part 1:

Purpose (reason to act) + Mastery (ability to act) = Motivation (willingness to act) 
The inability to meet metrics that are deemed relevant and fair establishes a purpose, a reason to act, although the metrics we use are really just a first step, not the end goal. For instance, a long door-to-doctor time is a department issue that reflects a quality risk for patients who wait to be evaluated, a very relevant concern and a fair measurement. However, it is determined by the actions of many people, leaving the individual doctor at risk for the actions of others, which is an unfair proposition.  Portrayed as a department issue, people are much more willing to engage in identifying their particular contribution. Identify that portion of the metric that directly depends on the doctor's decisions and actions, and we identify where the doctor can act. Mastery requires sufficient ability to perform the required tasks, but also the ability to see where you can act to have a positive impact.  To develop mastery, feedback is essential to know if your actions produce the intended effect, but it has to be the right kind of feedback to avoid turning people off.

Motivation + Autonomy (latitude to act) = Engagement (investing of oneself to act)
In the ED, autonomy means giving people the latitude to prioritize their work. What do you do next if you have a patient ready for discharge; a patient who the nurse has asked you to reevaluate for pain control, a new chart in the rack, and a patient ready for the hospitalist? What does a nurse do first if they have a patient ready to go upstairs, a new patient, a patient to be medicated and a patient ready for discharge? How do their choices affect you? What happens to the nurses, secretaries, and department flow when you and your colleague each give the hospitalist two admissions at the same time (not to mention how the hospitalist feels)?  

One suggestion that might guide this prioritization would be that, short of a resuscitation the choice should be the patient who can be advanced to their next step the quickest.  This standard gives the flexibility to adjust frequently, while always keeping the work for every patient moving forward toward disposition. Standard routines improve individual work flow by reducing the time it takes to make decisions. But it also makes work more predictable, enabling others to better coordinate their efforts with yours.  

It is this skill of prioritizing individual work in the context of the entire department that is crucial to ED flow.  This requires real time minute by minute assessment of the current condition, identification of any challenges to that condition, and action to control the situation. The only people who can do this 24/7 are the ED staff on duty at the time. But with the infinite array of possibilities, it is impossible to create a step by step protocol for each potential circumstance. To be effective, staff needs some guidance. Here's an example:

Operational Theme:
Maintain an empty waiting room

  • To do this requires we have an appropriate place to put a newly arriving patient
  • To do this means we must have a space for them
  • To do this means we have to disposition a patient to clear that space  

Management means putting this theme into operation by  placing the priorities in the right order, delineating the possible options for response, supporting the real time decision making by people with skills and understanding to make these judgments, and then trusting people to make the best decision at that time. When faced with many possible options, applying the operational theme with the above standard enables a choice that makes the most sense for you as well as the most sense for the department. For instance, where does the charge nurse deploy staff if there are two discharges, an admission ready to go upstairs, and five new patients at triage?  According to this operational theme and prioritization standard, the response would be the discharges first and the admissions next. But, without knowing the condition of these new arrivals at triage, it is impossible to know if there is a time sensitive issue there. Perhaps additional assistance for the triage nurse is needed for a brief time to ascertain the situation there first before focusing on the disposition.  

Prioritization, then, requires an established real time communication scheme. This dialogue is crucial to determine minute by minute what each individual needs to be successful in the work they are responsible for, enabling an effective negotiation that meets the most needs by the most people at that moment. In many departments, this is based on an informal system which relies on individuals having worked together for some time and understanding how everyone else prefers to do their work. In most places, this works well, until there is a change which disrupts those connections. With the increasing turnover of doctors, nurses, staff and administrations, how do you replace or establish this informal network quickly when there is a change? Do you have some guidelines as to how this communication takes place? For instance, how and when does the nurse need to know the doctor's thoughts and plan for a particular patient? Does this need to happen for every patient or just the complex and complicated? At what point does the nurse inform the doctor about a patient's progress? How does the nurse know when a patient is being admitted, so they can begin the preparation work for that? How does the charge nurse stay aware of the changing circumstances? 

Prioritizing individual work tasks within the context of department performance at any given time requires some established guidance and a good communication scheme.  To successfully deliver good care to every patient in the department requires giving staff the latitude and support to make these decisions.  This requires an engaged staff. This approach does, however, challenge many of the currently accepted management beliefs and practices and can place leadership and managers in a vulnerable position, at risk from the decisions made by others. What this calls for is a troubleshooting guide to assist managers and possibly some different language. We'll cover this in the final installment.

Benchmarking: So You Think You Are Good, Compared to What? - Quality Improvement & Patient Safety Section Newsletter, June 2012

Dickson Cheung, MD, MBA, MPH

Dr. Dickson CheungExcuse my fixation. I just returned from another year of training from the Baldrige Performance Excellence Program. It is the nation’s only quality award on high performing organizations. And they’ve had me musing about benchmarking, or in Baldrige language, comparisons.  

Back in my statistics and epidemiology classes, one concept that was forever imprinted on me was the concept of comparisons. I was taught that whenever you hear a raw number or a ranking in isolation, you should ask the question, “Compared to what?” That is the key question. For example, I recently heard a boast, “Our hospital is #1 with respect to psychiatric bed access.” Sounds good, doesn’t it? But what comparisons matter? Local, regional, national? The competitor hospital down the street or the “in system” hospital across the country? This largely depends on what your organizational goal is. 

I am not a golfer. The first time I stepped onto a course I was in the fourth decade of my life. Three years into marriage, my wife and I decided to pick up the game because it was something we could learn together without getting all competitive. Mostly, it gave us time to chat, enjoy some scenery and get a little exercise. One thing that strikes me as very unique about this gentleman’s game is that serious golfers always seem to know the score of their last round. “I shot an 85 on that course with a handicap of 9.” I have no idea if that last quote makes sense. Again, I am not a golfer. But what impresses me is that golfers are not only cognizant of current performance but they measure themselves against an objective and personal “standard.” 

After 22 years of essentially doing nothing as an alumnus to support my college alma mater, I decided to “give back.” I began interviewing high school students and writing reports for their admissions portfolio. It is relatively easy for me to do since I have some experience interviewing applicants for medical school and residency programs. What presented as an unexpected challenge, however, was how to “benchmark” these gifted high school students. How do you take into account the competitiveness of their high schools, grades and awards? Grade inflation is so rampant nowadays that letter grades are virtually meaningless. Sure there are standardized test scores but I am not privy to them. Even if I was, they are not risk-adjusted measures of present performance, or more importantly, predictors of future success? The idealistic side of me expects more out of students that are given better opportunities. 

So what do golfers, student applications and healthcare systems have in common? Measures and their related benchmarks have become the method of choice how hospitals and individuals judge themselves and each other. Comparisons of these quality measures are increasingly common. The Hospital Compare website has been up for years. The Physician Compare website booted up last year and will be populated with data by January 2013. It is unclear if any of these websites are useful to patients but that is another newsletter article. Rewards and penalties based on these comparisons will forever change the landscape on how we are reimbursed. And it should. I just wish that the science and methodology would catch up with its intent.  

The argument that inevitably comes up in benchmarking discussions is that the comparisons are “not fair.” “We’re different,” naysayers complain. And I agree it is not fair. But funny how human reactions work. I never hear how “unfair” it is because “we have all these advantages” (e.g. better payer mix, new building, etc). But rather, “woe is me because we’re disadvantaged” (e.g. sicker patients, safety net hospital, teaching institution, regulatory burdens, etc). You always hear how poorer schools feel that standardized tests are unfair. But do you ever hear schools at the top point out that their superior rankings are due to better resources? Statisticians deal with these biases with risk-adjustment. Business folks segment their market to derive more fair comparisons. But in healthcare, we have a long way to go before we can make valid risk-adjustments to measures for such initiatives as the Hospital Readmission Reduction Program and the Episodes of Care models in the value-based purchasing paradigm.  

Benchmarking is all about judging and improving performance. I am glad such organizations as the Emergency Department Benchmarking Alliance ( exist. And be thankful for national databases such as the Healthcare Cost and Utilization Project ( and the Medical Expenditure Panel Survey ( to help guide what is roughly expected for various subgroups. Too bad the National Hospital Ambulatory Medical Care Survey (NHAMCS) is gone. But what we could really use is a collaborative ED specific registry to track performance and create valid risk-adjustments. 

Still, the most important question to ask in our quest to benchmark is “what is the goal?” I sincerely hope it is to create better systems and better care for our patients. Not just an increase in market share, higher executive bonuses or even bragging rights. But I am skeptical. Remember my earlier example of how our psychiatric services are “#1?” The truth is that we often have psychiatric patients that stay in the ED on an order of days. It is true that compared to the rest of the Denver market, we are “#1” but compared to the rest of the nation, we are ranked #50 out of 50 states for psychiatric bed access. But for now, our administrators are satisfied that we are better than the hospital down the street. 

I’ll leave you with this joke I heard at a sermon last month and thought was very germane to this topic of comparisons and benchmarking. 

Two campers are walking through the forest when they suddenly encounter a grizzly bear.
The bear rears up on his hind legs and lets out a terrifying roar. 
Both campers are frozen in their tracks. 
The first camper whispers, "I'm sure glad I wore my running shoes today." 
"It doesn't matter what kind of shoes you're wearing, you're not gonna outrun that bear," replies the second. 
"I don't have to outrun the bear, I just have to outrun YOU," he answers.  

Use benchmarks to actually improve your organizations in these challenging times. Not, in the words of a popular reality TV show, to just “outwit, outplay, [and] outlast” the other guy. 

Residents' Section: Care at Arrival - Quality Improvement & Patient Safety Section Newsletter, June 2012

Shelby Kaplan, PGY 3 Resident, Department of Emergency Medicine
Michael Schmidt, Medical Director, Department of Emergency Medicine
Sanjeev Malik, Assistant Medical Director, Department of Emergency Medicine
Northwestern University, Department of Emergency Medicine
Northwestern Memorial Hospital
Chicago, Illinois

Care at Arrival  

The Problem  

Overcrowding continues to be a problem for emergency departments (EDs) with deleterious effects on quality of care (including delays of diagnostic/treatment decisions, patients leaving without completion of care, prolonged pain and suffering), patient satisfaction, physician productivity, and staff satisfaction [1].  To avoid compromising quality and patient safety, EDs must explore innovative ways to meet the volume demands. 

When it comes to challenges in patient flow that contribute to overcrowding, EDs often have little control over how and when patients arrive and even less control over outflow into the hospital.  However, we do have significant influence with throughput.  Efforts to improve patient flow through the ED should concentrate on inflow and throughput, while still working with hospital administrators and inpatient providers to manage hospital capacity issues and optimize outflow. 

Delayed initiation of care is a notable legal argument in many ED cases.  Additionally, a recent CNN article entitled “Don’t die waiting in the ER” received national attention.  Like many hospitals in the United States, we too have encountered similar challenges associated with rising ED volumes, hospital capacity, and notably, an increase in patient acuity.  During peak volume times each day, the number of presenting patients quickly exceeds the ED bed and staff capacity, resulting in a large number of patients in the waiting room waiting to be evaluated.  Left without being seen (LWBS) rates can exceed 5% on such days.  Studies show these long wait times are, in addition to being unsafe, unsatisfactory to patients [2].

The Current State  

In the traditional triage system utilized by the majority of U.S. emergency departments, a patient can go through fifteen or more individual steps before being seen by a physician, including having their name entered into the system, registration, vital sign collection, and assessment by one (or more) triage nurses.  According to a 2006 CDC report, patients currently wait an average of 55.8 minutes and a median of 31 minutes to be seen by a physician in emergency departments nationwide [3].  While the traditional triage system does meet the intended goal of prioritizing patients, using it in conjunction with traditional operations often results in patients not receiving care or even triage itself within the recommended time frames. [4] It may then be worthwhile to reconsider how emergency departments intake patients in order to get patients to the care they deserve. Eliminating redundancy, deleting the steps with no added value, and performing these steps in parallel, rather than in series, are some of the solutions to hasten triage and initiate care more rapidly. 

Possible Innovations for the Future  

Numerous studies and expert analyses have reported new strategies of triage as a means of improving patient flow and overall department efficiency.  Some innovative patient intake models have explored placing a mid-level provider in triage, placing a physician in triage, creating a triage team (composed of physicians, nurses, paramedics/technicians, and a clerk), avoiding triage completely and placing patients straight into exam rooms, creating intake kiosks, using bio-identification techniques to track patients, and using computerized self-triage. [5-9]  

Brief Literature Review  

Studies evaluating these different triage methods focus on the following outcomes:

  1. Throughput metrics including wait time, number of patients waiting, total length of stay (LOS), door-to-physician time, door-to-disposition time, and percent of patients leaving without being seen (LWBS)
  2. Patient satisfaction scores
  3. Staff satisfaction
  4. Quality metrics (such as time-to-antibiotics in community acquired pneumonia, time to EKG and PCI in acute myocardial infarction)
  5. Revenue

Prior studies have demonstrated that the percentage of patients who leave without being seen is significantly decreased by either a physician in triage [10] or team triage [8]. Prior studies have also shown a significant decrease in the total length of stay by a physician in triage [11-13] or team triage [8].   

The Northwestern Experience  

Northwestern Memorial Hospital is an urban, tertiary care center with an annual census of almost 90,000 patients/year.  Uniquely, we expanded to a second floor, and quickly reached capacity once again, forcing us to look to other inflow and throughput interventions.  

In designing our new triage process, we held weekly departmental operations committee meetings (consisting of attending and resident physicians, nursing managers and ED nurses, and hospital administrators) for six months focused on identifying key weaknesses and strengths.  Several of the committee members visited another similar volume emergency department to observe their current team triage model, which has demonstrated improvements in multiple performance metrics as well as satisfaction [8]. 

Ultimately, we developed our own model incorporating components of physician in triage, team triage, and triage space redesign.  Now, when patients enter our ED (either by walking in or via EMS), they are immediately seen in an Intake 1 area that is staffed by an RN who greets them and performs a 30-second evaluation and quick look to determine if they are critically ill and in need of an immediate bed.  A registration clerk simultaneously listens and enters basic patient information.  If deemed not to be critical, the Intake 1 RN then determines if there is an available ED space where they can immediately go for definitive care (first floor, second floor, or lower acuity area), and if not, the patient moves to the Intake 2 area.  There are designated chairs where patients may have to wait (for a short time) for Intake 2 evaluation in the event of a queue.  The Intake 2 team is staffed by four RNs, one physician, and two technicians (one to assist the RNs with obtaining vital signs, drawing blood, and wound care and one to obtain EKGs).  The Intake 2 areas are designed for patient evaluation by an RN, intended to take between five and seven minutes.  This is where rapid triage takes place and care is initiated, in coordination with the physician, including drawing labs, starting IVs, administering medications, and ordering diagnostic radiology studies.  The patients are assigned to the care under this same intake 2 RN until they are either roomed in an ED bay or discharged. 

While in Intake 2, some patients are evaluated by the triage physician who is responsible for their rapid medical assessment and initiation of their care.  Brief documentation of assessment, plan, and treatment is documented in the emergency medical record with the assigned team expected to complete formal evaluation and documentation.  This physician is also responsible for determining the final disposition of a portion of these patients, whether they are to be admitted or discharged.  Ultimately, the triage physician is responsible for managing the flow of Intake 2.  When this triage system is fully implemented, a resident physician will join the attending physician.  After being evaluated in Intake 2, patients are either 1) discharged, 2) moved to the post-processing area where they wait for further workup to be admitted, moved to an ED bay, or discharged, 3) moved to the ED bay queue (where they will wait in the waiting room for placement in an ED bay), or 4) directly roomed in an ED bay.  Additionally, the charge nurses of the first and second floor ED main rooms are primarily responsible for optimizing ED bed utilization and the outflow of patients from the intake areas rather than managing inflow. 

The following measures are being assessed:

  1. Throughput metrics: door-to-MD, and door-to-care initiation, length of stay, LWBS
  2. Patient and Staff satisfaction
  3. Time-dependent quality measures

To date, we have conducted a pilot of this new triage system one day/week over several weeks and have compared performance metrics to standard triage days.  We have found reductions in door-to-physician time, door-to-care initiation time, overall length of stay, length of stay for both admitted and discharged patients, and the percentage of patients who left without being seen.  

The following are preliminary data of averages comparing pilot days v. comparative select Mondays.  Patient volume: 270/day v. 252/day.  Door-to-MD: 39 min v. 78 min.  Door to care initiation: 12 min v. 18 min.  LWBS: 1% v 5%.  LOS: 4.9 hrs v. 5.5 hrs. Admit LOS: 7.2 v. 7.5.  Discharge LOS: 4.1 hrs v. 4.8 hrs.  Patient satisfaction and quality measures are still being analyzed. 

Clinical leadership, management and front-line care providers have been fully engaged in working through this significant change to the way care is provided, beginning at patient arrival.  A cultural shift has been set into motion and ED care providers increasingly understand the value in this endeavor, at times even becoming frustrated with any patients waiting, employing dynamic and team-oriented solutions on-the-fly.  A new palpable energy can be felt throughout the department.  We are hopeful this will continue as we analyze initial efforts and redesign intake to maximize throughput and meet our patients’ healthcare needs. 


  1. Derlet RW, Richards JR.  Overcrowding in the nation's emergency departments.  Annals of Emergency Medicine. 2000; 35 (1): 63.
  2. Emergency Department Pulse Report 2008. Patient Perspectives on American Health Care. South Bend, IN: Press Ganey Associates; 2008.
  3. Pitts, SR et al.  National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary.  National Health Statistics Reports.  August 6, 2008; 7.
  4. Weber, EJ, McAlpine I, Grimes B. Mandatory triage does not identify high acuity patients within recommended time frames. Annals of Emergency Medicine. 2011; 58(2): 137-42.
  5. Welch, SW, Davidson, S.  Exploring New Intake Models for the Emergency Department.  American Journal of Medical Quality.  2010; 25(3): 172.
  6. Oredsson, S et al.  A systematic review of triage-related interventions to improve patient flow in emergency departments.  Journal of Trauma, Resuscitation and Emergency Medicine.  2011; 19(43).
  7. Rowe, BH et al.  The role of triage liaison physicians on mitigating overcrowding in emergency departments: a systematic review.  Academic Emergency Medicine.  2011; 18:111-120.
  8. White, BA et al.  Supplemented triage and rapid treatment (START) improves performance measures in the emergency department.  Journal of Emergency Medicine 2012; 42(3).
  9. Welch, SW.  Door-to-doctor times: all patients really want is a physician.  Emergency Medicine News.  2006; 28(11): 10.
  10. Han, JH et al.  The effect of physician triage on emergency department length of stay.  Administration of Emergency Medicine.  2008; 39(2): 227.
  11. Holroyd, BR et al.  Impact of a triage liaison physician on emergency department overcrowding and throughput: a randomized controlled trial.  Academic Emergency Medicine.  2007; 14(8): 702.
  12. Russ, S. et al.  Placing physician orders at triage: the effect on length of stay.  Annals of Emergency Medicine.  2010; 56(1): 27.
  13. Partovi, SN et al.  Faculty triage shortens emergency department length of stay.  Academic Emergency Medicine.  2001; 8(10): 990.

EMPSF Emergency Care Patient Safety Summit - Quality Improvement & Patient Safety Section Newsletter, June 2012


EMPSF 2nd Annual Emergency Care Patient Safety Summit

On March 22 & 23, 2012, EMPSF held its 2nd Annual Patient Safety Summit: From Insights to Outcomes: Getting Results!  The meeting brought together key stakeholders and thought leaders from across the emergency care continuum.  Among the distinguished panel of speakers were the presidents of the American College of Emergency Physicians, Emergency Nurses Association, National Patient Safety Foundation and the American Society for Healthcare Risk Management. The meeting represented a cross-section of the emergency medicine community with representatives and patient safety experts from over 21 states and Canada participating. 

The purpose of the Summit was to convene a forum for those who practice in or manage emergency departments to discuss the opportunities and challenges related to improving patient safety in emergency care.  The Summit was successful in engaging the emergency medicine community in a focused dialog on many of the key patient safety issues as well as providing several solution oriented presentations. Some of the topics presented included: Standardization, Patient Safety and Medical Error; ED Performance Measures: Safety & Satisfaction; Use of Interpreters and Low Literacy; Results of the MCIC & Johns Hopkins Patient Safety Collaborative; Teaching Human Factors in Medical Education; Building High Functioning Teams via TeamStepps; Call Back Systems; The Impact of EDIS and EMR’s and patient safety; Violence in the ED; Prescription Drug Abuse; Medication Errors and the Role of the Pharmacist in the ED and more. 

Upon the conclusion of the Summit, participants had made valuable new contacts, renewed relationships with peers and mentors and had learned from experts in the field of emergency care patient safety. Armed with new information, contacts and a re-energized commitment to being a change agent for patient safety, participants of the 2nd Annual Patient Safety Summit are now sharing this experience with their colleagues. EMPSF is currently developing new education and collaboration tools to continue to stimulate the dissemination of new insights.  

The Summit has been designed as an annual event and a cornerstone of EMPSF’s yearlong calendar of education, research, collaboration and training programs. Planning for the 3rd Annual Summit in the spring of 2013 is underway and a save the date will be out soon. For those interested in presenting, exhibiting or attending the Summit, please contact EMPSF’s executive director, Dianne Vass, at

EMPSF is a national, non-profit organization dedicated to advancing patient safety in emergency care through education, research, collaboration and training. Since its founding in 2003, EMPSF has provided a grant and fellowship program to fund patient safety fellows to conduct research in emergency medicine.  As a membership based organization, we invite you to visit our website at and join our patient safety community!  For more information, please call 916.357.6723. 

QIPS TIPS: Sentinel Events in Healthcare: How to Respond - Quality Improvement & Patient Safety Section Newsletter, June 2012

QIPS TIPS #13 - Sentinel Events in Healthcare: How to Respond Part 1   

Shari Welch, MD, FACEP
Intermountain Institute for Health Care Delivery Research
Salt Lake City, UT

Shari WelchIn healthcare as in other service industries error free performance is never possible. Unfortunately, unlike most other service industries the stakes are the highest possible in healthcare with patients well- being and even their lives on the line.  Every day clinical adverse events occur within our healthcare system causing physical and psychological harm to patients, families, staff and the organization.

Although increasingly healthcare organizations are establishing disaster management strategies, and putting policies and programs in place, these are not the perfect mechanisms that are needed when a clinical crisis occurs in healthcare.  

In 2010 the Institute for Healthcare Improvement (IHI) posted a brief whitepaper on its website titled “Respectful Management of Serious Clinical Adverse Events” (Conway J, IHI Innovation Series Whitepaper 2011).  Within 9 months of its posting there were 34,000 visits to the site and 12,000 downloads of this paper, suggesting that there was a void existing in healthcare with regard to responding to sentinel events. In November of 2011 IHI posted a more detailed second version with expanded resources for managing the unthinkable in healthcare. 

What differentiates healthcare organizations positively or negatively is their culture of safety and whether they choose to react defensively and reactively or whether they choose to become proactive in embracing their errors and managing them strategically.  According to IHI when a sentinel event occurs and they are called to assist leadership, there are certain features of such events that recur:

  1. Personal devastation of the individual calling
  2. Similarities of stories, no matter the different details
  3. An organizational response built from scratch
  4. An operating style that is reactive
  5. The tendency to underestimate the potential harm to all

Crisis Management as a discipline is less than 30 years old.  But many of its strategies can be applied and adapted to Clinical Crises and Adverse Events Management.  The point is that the response to any sentinel event ought not be ad hoc; policies, procedures, a team and a plan ought to be crafted in advance of such events. The IHI whitepaper offers a treasure trove of tools and resources to that end.  A checklist, a work plan, a list of organizations who have weathered a clinical crisis and will offer their experiences and support, and other supporting documents can be found in the appendices to this paper.   

In broad brush strokes the healthcare organization needs to at least be prepared to address the following: Avoid the Crisis, Recognize the Crisis, Manage the Crisis, Resolve the Crisis and Learn from the Crisis. More on the particulars of setting up a Crisis Management Plan for healthcare mishaps that can be implemented system wide next edition.

QIPS Resident Quality Award - Quality Improvement & Patient Safety Section Newsletter, June 2012

QIPS Resident Quality Award 
Submission Deadline: August 1, 2012 

The Quality Improvement & Patient Safety (QIPS) Resident Quality Award, established in 2010, will be presented to residents graduating within the calendar year. Recipients of the award will receive a free 1-year QIPS membership, publication in the QIPS Newsletter and recognition at the 2012 ACEP Scientific Assembly in Denver, CO!  

Projects will be judged on their overall importance, innovation, approach and applicability to the general Emergency Medicine community.  

**This form must accompany each nomination.**  



Quality and Safety Articles - Quality Improvement & Patient Safety Section Newsletter, June 2012

Here is a selected list of recent articles for your interest. These are distributed by AHRQ PSNet at ( ).  

Helmut Meisl MD FACEP
May 20, 2012

meislInterruptions and miscommunications in surgery: an observational study.
Interruptions and miscommunications in surgery: an observational study.
Gillespie BM, Chaboyer W, Fairweather N. AORN J. 2012;95:576-590.

Language barriers and understanding of hospital discharge instructions.
Karliner LS, Auerbach A, Nápoles A, Schillinger D, Nickleach D, Pérez-Stable EJ. Med Care. 2012;50:283-289.

Evaluating alert fatigue over time to EHR-based clinical trial alerts: findings from a randomized controlled study.
Embi PJ, Leonard AC. J Am Med Inform Assoc. 2012 Apr 25; [Epub ahead of print].

Patients' willingness and ability to participate actively in the reduction of clinical errors: a systematic literature review.
Doherty C, Stavropoulou C. Soc Sci Med. 2012 Apr 13; [Epub ahead of print].

Cognitive interventions to reduce diagnostic error: a narrative review.
Graber ML, Kissam S, Payne VL, et al. BMJ Qual Saf. 2012 Apr 27; [Epub ahead of print].

What did the doctor say? Health literacy and recall of medical instructions.
McCarthy DM, Waite KR, Curtis LM, Engel KG, Baker DW, Wolf MS. Med Care. 2012;50:277-282.

To tell the truth, the whole truth, may do patients harm: the problem of the nocebo effect for informed consent.
Wells RE, Kaptchuk TJ. Am J Bioeth. 2012;12:22-29.

Emergency department crowding and risk of preventable medical errors.
Epstein SK, Huckins DS, Liu SW, et al. Intern Emerg Med. 2012;7:173-180.

The relationship between organizational culture and family satisfaction in critical care.
Dodek PM, Wong H, Heyland DK, et al. Crit Care Med. 2012;40:1506-1512.

Comparative economic analyses of patient safety improvement strategies in acute care: a systematic review.
Etchells E, Koo M, Daneman N, et al. BMJ Qual Saf. 2012 Apr 22; [Epub ahead of print].

Patient safety: break the silence.
Johnson HL, Kimsey D. AORN J. 2012;95:591-601.

Human factors–focused reporting system for improving care quality and safety in hospital wards.
Morag I, Gopher D, Spillinger A, et al. Hum Factors. 2012;54:195-213.

The association of workflow interruptions and hospital doctors' workload: a prospective observational study.
Weigl M, Müller A, Vincent C, Angerer P, Sevdalis N. BMJ Qual Saf. 2012;21:399-407.

The science of interruption.
Coiera E. BMJ Qual Saf. 2012;21:357-360.

Medication reconciliation in the hospital: what, why, where, when, who and how?
Fernandes O, Shojania KG. Healthc Q. 2012;15:42-49.

Prevalence of error-prone abbreviations used in medication prescribing for hospitalised patients: multi-hospital evaluation.
Dooley MJ, Wiseman M, Gu G. Intern Med J. 2012;42:e19-e22.

Nurses' practice environments, error interception practices, and inpatient medication errors.
Flynn L, Liang Y, Dickson GL, Xie M, Suh DC. J Nurs Scholarsh. 2012 Apr 17; [Epub ahead of print].

Prevalence of preventable medication-related hospitalizations in Australia: an opportunity to reduce harm.
Kalisch LM, Caughey GE, Barratt JD, et al. Int J Qual Health Care. 2012 Apr 11; [Epub ahead of print].

How reliable are clinical systems in the UK NHS? A study of seven NHS organisations.
Burnett S, Franklin BD, Moorthy K, Cooke MW, Vincent C. BMJ Qual Saf. 2012 Apr 11; [Epub ahead of print].

Multiple patient safety events within a single hospitalization: a national profile in US hospitals.
Yu H, Greenberg MD, Haviland AM, Farley DO. Am J Med Qual. 2012 Apr 10; [Epub ahead of print].

Errors of medical interpretation and their potential clinical consequences: a comparison of professional versus ad hoc versus no interpreters.
Flores G, Abreu M, Barone CP, Bachur R, Lin H. Ann Emerg Med. 2012 Mar 14; [Epub ahead of print].

Comparing two safety culture surveys: Safety Attitudes Questionnaire and Hospital Survey on Patient Safety.
Etchegaray JM, Thomas EJ. BMJ Qual Saf. 2012 Apr 11; [Epub ahead of print].

Apology for errors: whose responsibility?

Leape LL. Front Health Serv Manage. 2012;28:3-12.

Failure mode and effects analysis: too little for too much?
Franklin BD, Shebl NA, Barber N. BMJ Qual Saf. 2012 Mar 23; [Epub ahead of print].

A review of patient safety measures based on routinely collected hospital data.
Tsang C, Palmer W, Bottle A, Majeed A, Aylin P. Am J Med Qual. 2012;27:154-169.

Identifying nontechnical skills associated with safety in the emergency department: a scoping review of the literature.
Flowerdew L, Brown R, Vincent C, Woloshynowych M. Ann Emerg Med. 2012 Mar 14; [Epub ahead of print].

Analysis of risk factors for adverse drug events in critically ill patients.

Kane-Gill SL, Kirisci L, Verrico MM, Rothschild JM. Crit Care Med. 2012;40:823-828.

Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients.
Cornu P, Steurbaut S, Leysen T, et al. Ann Pharmacother. 2012 Mar 13; [Epub ahead of print].

I-PASS, a mnemonic to standardize verbal handoffs.
Starmer AJ, Spector ND, Srivastava R, Allen AD, Landrigan CP, Sectish TC; I-PASS Study Group. Pediatrics. 2012;129:201-204.

Economic evaluation in patient safety: a literature review of methods.
Alves de Rezende B, Or Z, Com-Ruelle L, Michel P. BMJ Qual Saf. 2012 Mar 6; [Epub ahead of print].

Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States.

Aiken LH, Sermeus W, Van den Heede K, et al. BMJ. 2012;344:e1717.

Detecting unapproved abbreviations in the electronic medical record.
Capraro A, Stack A, Harper MB, Kimia A. Jt Comm J Qual Patient Saf. 2012;38:178-183.

Medical error, incident investigation and the second victim: doing better but feeling worse?
Wu AW, Steckelberg RC. BMJ Qual Saf. 2012;21:267-270.

Impact of resident workload and handoff training on patient outcomes.
Mueller SK, Call SA, McDonald FS, Halvorsen AJ, Schnipper JL, Hicks LS. Am J Med. 2012;125:104-110.

Minimizing inappropriate medications in older populations: a ten-step conceptual framework.
Scott IA, Gray LC, Martin JH, Mitchell CA. Am J Med. 2012 Feb 29; [Epub ahead of print].

Achieving a high-reliability organization through implementation of the ARCC model for systemwide sustainability of evidence-based practice.
Melnyk BM. Nurs Adm Q. 2012;36:127-135.

Medical error disclosure: the gap between attitude and practice.
Ghalandarpoorattar SM, Kaviani A, Asghari F. Postgrad Med J. 2012;88:130-133.

Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review.
Lawton R, McEachan RRC, Giles SJ, Sirriyeh R, Watt IS, Wright J. BMJ Qual Saf. 2012 Mar 15; [Epub ahead of print].

Disclosure of "nonharmful" medical errors and other events: duty to disclose.
Chamberlain CJ, Koniaris LG, Wu AW, Pawlik TM. Arch Surg. 2012;147:282-286.

The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care.
Wohlauer MV, Arora VM, Horwitz LI, Bass EJ, Mahar SE, Philibert I. Acad Med. 2012 Feb 22; [Epub ahead of print].

Restricting resident work hours: the good, the bad, and the ugly.
Peets A, Ayas NT. Crit Care Med. 2012;40:960-966.

Medication errors: when pharmacy is closed.
PA-PSRS Patient Saf Advis. March 2012;9:11-17.

Assessment of adverse events in medical care: lack of consistency between experienced teams using the Global Trigger Tool.
Schildmeijer K, Nilsson L, Arestedt K, Perk J. BMJ Qual Saf. 2012 February 23; [Epub ahead of print].

Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements.
DeRienzo CM, Frush K, Barfield ME, et al. Acad Med. 2012 Feb 22; [Epub ahead of print].

Effects of an educational patient safety campaign on patients' safety behaviours and adverse events.
Schwappach DLB, Frank O, Buschmann U, Babst R. J Eval Clin Pract. 2012 Feb 14; [Epub ahead of print].

A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis.
Avery AJ, Rodgers S, Cantrill JA, et al. Lancet. 2012 Feb 20; [Epub ahead of print].

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.
Salanitro AH, Osborn CY, Schnipper JL, et al. J Gen Intern Med. 2012 Feb 15; [Epub ahead of print].

The costs of adverse drug events in community hospitals.
Hug BL, Keohane C, Seger DL, Yoon C, Bates DW. Jt Comm J Qual Patient Saf. 2012;38:120-126.

Medicaid, hospital financial stress, and the incidence of adverse medical events for children.
Smith RB, Dynan L, Fairbrother G, Chabi G, Simpson L. Health Serv Res. 2012 Feb 21; [Epub ahead of print].

Learning from near misses: from quick fixes to closing off the Swiss-cheese holes.
Jeffs L, Berta W, Lingard L, Baker GR. BMJ Qual Saf. 2012 Feb 22; [Epub ahead of print].

A handoff is not a telegram: an understanding of the patient is co-constructed.
Cohen MD, Hilligoss B, Kajdacsy-Balla Amaral AC. Crit Care. 2012;16:303.

Effects of an educational patient safety campaign on patients' safety behaviours and adverse events.
Schwappach DLB, Frank O, Buschmann U, Babst R. J Eval Clin Pract. 2012 Feb 14; [Epub ahead of print].

Look-alike and sound-alike medicines: risks and 'solutions.'
Emmerton LM, Rizk MFS. Int J Clin Pharm. 2012;34:4-8.

Reviewing the impact of computerized provider order entry on clinical outcomes: the quality of systematic reviews.
Weir CR, Staggers N, Laukert T. Int J Med Inform. 2012 Feb 17; [Epub ahead of print].

Design and implementation of an automated email notification system for results of tests pending at discharge.
Dalal AK, Schnipper JL, Poon EG, et al. J Am Med Inform Assoc. 2012 Jan 19; [Epub ahead of print].

Weekend hospitalization and additional risk of death: an analysis of inpatient data.
Freemantle N, Richardson M, Wood J, et al. J R Soc Med. 2012 Feb 6; [Epub ahead of print].

Evaluation of organizational culture among different levels of healthcare staff participating in the Institute for Healthcare Improvement's 100,000 Lives Campaign.
Sinkowitz-Cochran RL, Garcia-Williams A, Hackbarth AD, et al. Infect Control Hosp Epidemiol. 2012;33:135-143.

Risk factors for patient-reported medical errors in eleven countries.
Schwappach DL. Health Expect. 2012 Feb 1; [Epub ahead of print].

Is the drug shortage affecting patient care in your critical care unit?
Alspach JG. Crit Care Nurse. 2012;32:8-13.

Impact of vendor computerized physician order entry in community hospitals.
Leung AA, Keohane C, Amato M, et al. J Gen Intern Med. 2012 Jan 21; [Epub ahead of print].

Survey shows that at least some physicians are not always open or honest with patients.
Iezzoni LI, Rao SR, DesRoches CM, Vogeli C, Campbell EG. Health Aff (Millwood). 2012;31:383-391.

An examination of opportunities for the active patient in improving patient safety.
Davis RE, Sevdalis N, Jacklin R, Vincent CA. J Patient Saf. 2012 Jan 17; [Epub ahead of print].

The ins and outs of change of shift handoffs between nurses: a communication challenge.
Carroll JS, Williams M, Gallivan TM. BMJ Qual Saf. 2012 Feb 10; [Epub ahead of print].

Major cultural-compatibility complex: considerations on cross-cultural dissemination of patient safety programmes.
Jeong HJ, Pham JC, Kim M, Engineer C, Pronovost PJ. BMJ Qual Saf. 2012 Feb 10; [Epub ahead of print].

Stepping out further from the shadows: disclosure of harmful radiologic errors to patients.
Brown SD, Lehman CD, Truog RD, Browning DM, Gallagher TH. Radiology. 2012;262:381-386.

Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study.
Westbrook JI, Reckmann M, Li L, et al. PLoS Med. 2012;9:e1001164.

Click here to
send us feedback