CUTTING-EDGE DISCUSSIONS OF MANAGEMENT,POLICY, AND PROGRAM ISSUES IN

EMERGENCY CARE

Authors: Jeff Solheim, RN, CEN, CFRN, FAEN, andAnnMarie Papa, MSN, RN, CEN, CAN, FAEN, Doylestown, PA, and Keizer, OR

BENCHMARKING

As a new nurse manager, I am interested in

understanding how to measure my emergency

department’s performance and score it against

national benchmarks. Can you give me ideas on

how to get started, what to measure, and how to

benchmark it?

Answer 1:We believe the first thing to consider is the definition ofa benchmark. A benchmark is typically defined as a stan-dard or a best practice. The inherent problem with usingbenchmarks as standards is that there is variation in howbenchmarks are defined. For example, if you are measuringarrival to triage, and your average timeframe is 10 minutes,is that good? If the benchmark is 5 minutes, are you notperforming well? You may be measuring from arrival tocompletion of triage rather than start of triage. You may alsobe measuring arrival time as sign-in time whereas the com-parison may be from registration time, not sign-in time.Also, some emergency departments are measuring timeto provider as the time standing orders were initiated. Ifyou are using external benchmarks, it is essential to clearlydefine the metrics.

That is not to say that external benchmarks are nothelpful. They do provide you with an idea of how youcompare with peer organizations and what might bepossible as a target for your performance. However, youmay be limited in achieving the same level of perfor-

mance. We typically use the following as benchmarks forED operations:

• Arrival to triage, 5 minutes• Arrival to bed, 18 minutes• Arrival to provider, 30 to 40 minutes• Discharge length of stay, 120 minutes• Fast-track length of stay, 60 to 90 minutes• Admission length of stay, 230 minutes• Left without being seen (LWBS) rate, less than 2%

These benchmarks are often viewed as best practiceand certainly goals to strive for. However, we find thatsome patients will not be able to achieve these benchmarksbased on current staffing (both provider and nursing) andcapacity (both emergency department and inpatient). If thereis insufficient staffing to care for patients, you may be ableto achieve arrival to triage but you may struggle with arrivalto bed and arrival to provider, and your overall length of staywill be extended. If you have insufficient capacity withinyour emergency department, you will find that you will beunable to consistently meet these benchmarks and yourwalkout rate may increase.

The definition we use with our patients is that a bench-mark should be a point of reference. Internal benchmarks—comparing yourself with yourself—are a better indicationof how well you are improving. These benchmarks shouldbe measured on a daily basis (and sometimes on a shiftbasis) to determine how effective your processes are andwhat some of the root causes for failure may be. Forexample, your LWBS rate increased this month from3% to 3.4%. Why? By looking at LWBS patients on ashift basis and comparing that with volume and admissionholds, you can begin to see if there are relative patterns.Also, comparing shift LWBS rates with provider and nurs-ing staff may indicate the additional need for educationand follow-through.

In summary, benchmarks are an excellent way to mea-sure your baseline performance and to use to gauge theeffects of improvement initiatives. It is essential to make surethat the benchmark definitions are clear and that you are

The opinions expressed are those of the respondents and should not be con-strued as the official position of the institution, ENA, or the Journal.

J Emerg Nurs 2009;35:569-73.

Available online 11 September 2009.

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Copyright © 2009 Emergency Nurses Association. Published by Elsevier Inc.All rights reserved.

doi: 10.1016/j.jen.2009.08.007

M A N A G E R S F O R U M

November 2009 35:6 JOURNAL OF EMERGENCY NURSING 569

collecting information with enough frequency to identify andrespond to changes in performance.—James Hoelz, RN, MS,MBA, CEN, Managing Partner, Blue Jay Consulting, LLC,Philadelphia, PA; E-mail: jim.hoelz@bluejayconsulting.com

Answer 2:This issue of measuring performance, and benchmarkingcan stymie even the most seasoned ED leader. We aredoing a better job in health care making these metrics moretransparent to all in the hospital. And, increasingly, itis becoming part of the conversation with an informedpatient. I like to say “no good journey can begin withoutknowing where you are today.” Start with finding a balanceof metrics across the 3 interdependent functions in healthcare: clinical, operational, and financial. The metrics shouldbe consistent with the hospital’s strategic pillars. This willhelp to ensure visibility and sustainability.

Examples of metrics for your dashboard are as follows:

1. ClinicalA. Unscheduled returns within 72 hoursB. Number of fallsC. Incident of restraint usage and hoursD. Medication errors

2. OperationalA. Length of stay—overall, discharge, admitted, fast track,

boardersB. Patient satisfaction—can be specific focus (overall, like-

lihood to recommend, and so on)C. Door to bed and/or door to physicianD. Diversion hoursE. Left without being seenF. Laboratory and radiology turnaround timeG. Hours per patient visitH. Acuity spread—percent of emergency severity index

levels3. Financial

A. Point-of-service cash collectionsB. Payer mixC. Net revenue per patientD. Percent of overtimeE. Operating margin

After specific metrics have been chosen, definitionsshould be decided upon. There are resources availablethroughout the industry to help here. In 2006 a consensuspaper was published with industry definitions. In addi-tion, many information technology vendors and compa-nies specializing in performance will be able to guide thisdiscussion. The goal is to ensure that you are making a com-parison to similar measures. This is often where I encountera breakdown when working with a hospital.

Measuring the metrics may be a manual or electronicprocess. Either way, the collection method must be con-sistent and hardwired into the activities of leadership. Theuse of business intelligence tools that can measure acrosssystems and push information in real time is growing inpopularity. The business intelligence tools can take staticinformation, layer it together, and help with a more bal-anced analysis of performance.

The conversation of benchmarks is rabid in manycircles of health care. And, as patients are able to see per-formance on the Internet and other media sources, it isincreasing the importance of being able to talk aboutbenchmarks. Annually, the Centers for Disease Controland Prevention releases its National Hospital AmbulatoryMedical Care Survey. This commonly is used to comparewith individual ED performance. The ENA has a 2005benchmark publication, and there are commercial vendorswho will share information. All benchmarking sources havelimitations, and because of this, I have moved to consider“benchmarks” more of a “guidepost” to set your targets.Limitations include self-reported data, limited sample size,different definitions for the same metric, and difficultyusing broad-population metrics for specific hospital com-parison. Benchmarks should be directional for conversationand desire to improve. Realizing that pushing to improveone will affect another makes it tough to remain hard andfast on a single number. In addition, every hospital has nuan-ces (space, operational hours, acuity, specialty center, staffmix, technology) that must be considered in the equation.

Finally, make sure as a leader that the metrics are get-ting the attention needed. Introduce the important metricsto the staff, keep them posted for visibility, and share reg-ularly how their own work impacts the key metrics. Execu-tive leaders should also be sharing this information. Asboards and trustees of hospitals have become increasinglyunder pressure to improve performance, they have takenan interest and actively seek the information.

Some tips for benchmarking are as follows:

1. Use industry-accepted definitions for a metric.2. Measure regularly and report up and down the organization.3. Do not purely focus on one metric. It will lead to adverse

outcomes in other areas.4. Make decisions and set targets based on trends: monthly,

annually, seasonally, and so on. A singular change inmetrics may not need to be corrected.

5. Use benchmarks as guideposts to push leaders forimprovement and start discussions.—Fred Neis, RN,MS, FACHE, CEN, Senior Director, H*Works Consulting,The Advisory Board Company, Washington, DC; E-mail:fneis@ kc.rr.com

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CULTURE OF QUIET

We are working to reduce noise in our department

and promote a quieter atmosphere for our patients.

Recognizing that we work in an often busy and

bustling environment, how do you help facilitate this?

Answer 1:We use sound screens to help mask the sound. Soundscreens are “white noise” machines. Ours are short cylin-ders about 8 inches in diameter. They have 2 settings/volumes of the soft fan/vacuum-like noise. They are oftenused in physicians’ offices in the waiting area. Our ambula-tory surgical unit (ASU) started using them awhile back intheir large ASU area, which is divided only by curtains.They put one behind each stretcher. We started using themabout a year ago, and they do help cancel out quite a bit ofnoise that comes from outside of the room. It is certainlynot as nice as a TV but helps when you are trying to cutdown on what folks can hear in the department. Try theInternet and search for “sound screen.”—Chris Costello,RN, CEN, Director of Emergency & Obstetrical Services,Mount Desert Island Hospital, Bar Harbor, MN; E-mail:chris.costello@mdihospital.org

Answer 2:We have used white-noise machines with a fair amountof success. These do not block all the noise but they help.We also have mostly private rooms and a TV in everyroom, so that helps also.—Pam George, Director, EmergencyServices, Sharon Hospital, Sharon, CT; E-mail: pam.george@sharonhospital.com

NURSING CARE DELIVERY SYSTEMS

Has anyone attempted team or zone nursing?

Answer 1:With the growing numbers of patients being seen in ouremergency department, higher patient acuities, construc-tion barriers and challenges, and budget cuts and restraints,along with the ever-present nursing shortage, creativity andflexibility in staffing patterns have become the standardin the nursing care delivery system practiced in our depart-ment. No single care delivery system appears to fit the billfor the current state of affairs. We have found a need todevelop our own hybrid model based on day-to-day needsand sometimes through the trial and error of attempts.

Our facility is only 5 years old and in a growing area ofmetro/suburban Indianapolis. We originally had 12 ED

beds and 3 fast-track beds. Our projected patient numberour first year open was approximately 7,000; we saw nearly18,000. Our staffing and facility were therefore alreadystretched from the get-go. We are now seeing close to40,000 per year, and our patients are presenting sicker. Ibelieve our growth is a combination of a multitude of vari-ables. The community now knows we are here, so theycome; the economic crisis has created a population withlimited resources including preventive health care, makingED visits the only alternative; and we provide excellentcare with an excellent staff and therefore have gained thetrust of providers and patients.

With our growth, construction and remodeling toaccommodate our needs are currently under way but werebudgeted and planned approximately 2 years ago, makingus already 2 years behind our current growth needs. Ournew space will offer 19 ED rooms, 2 fast-track rooms, andlots of extra hall space to accommodate 8 hall beds for fast-track/ED flex needs. Our current geography has been ever-changing because of the construction. Rooms are open 1 dayand closed the next. Therefore staffing patterns have flexedroutinely. We have found challenges with communication,team work, the balance of work assignments, and the con-stant worry over patient safety during this flux.

We have been focusing on our geographic parametersfor staffing patterns. We have termed our patient care areasas “pods” for no other reason than their physical locationand distance from each other. We have currently put a con-test together for the naming of these pods to boost moraleand to promote unit ownership among our staff. Eachpod is designated based on acuity type, that is, the sickestpatients are in the largest rooms, closest to the ambulancebay, and closest to the nurse/doctor station. Fast track isclosest to the waiting room.

Our nurses originally practiced with assigned rooms.As we grew, they absorbed hall beds into their assignments.We hired more paramedics and EMTs to work as techni-cians to support task-oriented unit needs such as stockingrooms, ECGs, intravenous starts, and so on. They scatteredthemselves around the department, taking care of whateverpresented wherever it was.

Current budget restraints have limited hiring, and thecurrent supply of experienced emergency nurses has limitedthe filling of open positions. We have welcomed new staffwith open arms but have been challenged with meetingneeds of providing them with a healthy orientation andthe education to help them grow. Thank goodness forour new educator. We now hope to grow our own and nowhave student nurses added to our mix.

As we physically spread ourselves out, geographically,we implemented a team nursing model of care delivery.

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Each team consisted of 2 RNs and one technician with anassignment of 8 rooms and 2 hall beds on average (less inour higher-acuity rooms). The thought was that patientswould be admitted, monitored, and cared for by a team,with each patient having a “primary” nurse charting,administering medications, and orchestrating the flow butbalancing out the load among the team, again based onpatient acuity needs. Each team member would have aworking knowledge of all of the patients assigned to thatteam, allowing for safe handoffs for meal breaks, trans-ports, and so on. We balanced our teams with tenurednurses and less experienced nurses grouped together tofoster mentoring and teaching moments. This workedwhen everyone on the team was willing to work. However,the cream of the crop seemed to take on the most and theothers allowed this without stepping up. We hoped thatthe “lead by example” method would take root, but wefailed to provide the proper combination of soil, water, andair necessary for anything with a root to grow. Our “creamof the crop” now was curdled, wilted, and overwhelmed.

This method was quickly abandoned because of stafffrustrations and complaints. The theory was good, butour implementation of this system was poor. We hadimplemented changes in our system quickly, flexing toimmediate staffing needs, but had failed to recognize someof the barriers to making this successful. We were trying tochange the culture of nursing in our department. Although itwas in flux, it was comfortable. Changing the culture is likesteering a ship, it must be done slowly and methodicallywhile consistently assessing the wind, the waves, and thedestination, all while avoiding the icebergs. We hit icebergsand had to make repairs quickly before disaster sank our ship.

We then brought our thoughts back to our clinicalpractice committee (our lifeboat) for fine tuning and brain-storming. Our current practice is a hybrid of past attempts.We still group our staff within geographic pods. Our nursesare still teamed in groups of 2 RNs and one technician tocare for a total of 8 beds and 2 hall beds (which variesin some areas). However, we now assign specific roomsand the technician works only within the team for thetask-oriented needs. Our handoff for meal breaks andpatient transport is done at the bedside as a verbal reportbetween the “team” RNs. We also use our charge nurse as afloat nurse to iron out the kinks that present themselves.

This is all still a work in progress, and I believe it willalways be. We are now meeting weekly to address currentneeds—construction, staffing fluctuations, budget and hiringconstraints, and so on. We are creating a culture of flexibilityand accountability. We are getting more and more creativeevery day. We are growing as a team as we identify our needs,our goals, our concerns, and our dreams. We are all vested

in this process and are now seeing progress.—Caroline Lynn,RN, BSN, Shift Coordinator Emergency Department, ClarianWest Medical Center, Avon, IN; E-mail: clynn@clarian.org

Answer 2:As someone who has worked as staff in “team nursing”models, I would like to share my perspective on them.First, the output and flow of the patients as well as theproductivity of your staff will truly depend on who ison your team, and you have probably heard that from staffas you have been discussing it. The cream will truly rise tothe top in this process. Next, be proactive and assignrooms in the team. I realize this goes against the conceptof team nursing, but room checks, equipment checks, andso on will not get done. Everyone will assume someoneelse is doing them. The high performers in your depart-ments will excel and prove themselves as high performers,whereas the low performers will sit back and allow themiddle and high performers to do most of the work.

Some of the struggles involved the following:

• Patients lying in beds for extended periods of time withno nursing assessment or acknowledgement

• One nurse having 6 patients and the other having2 (acuity was not a factor)

• Teammates asking, “What do you need?” because theydid not step up to the plate and assume care of the patient.

• No one accepting patients from triage—“I already haveso many patients on my team” and so on

• Code carts and equipment not checked• No one accepting responsibility for roles that normallywent with team assignments

To address these issues, several resolutions were estab-lished. As staff, we did the wrong thing and created work-arounds that were not consistent; however, it helped tosurvive a shift. There was increased tension between thehigh performers and the low performers. Tensions ranhigh. If it was a good team, it was no sweat. With a badteam (so to speak), you find yourself going into survivalmode. I shared my thoughts with my director, and she sug-gested peer accountability. I remember saying to a super-visor and a charge nurse, “I will be a team player all daylong, just please give me back my room assignment.” Minewas not the only opinion of this process. We shared ourthoughts and concerns about the neglect in patient care,and thankfully, after a little over a month, we went to moreof a pod module with a “team” of 2 nurses, an NA and aprovider. However, as nurses, we had assigned rooms inthat pod. It was in reality nothing different from whatwe were doing before. However, I suppose we appreciatedit much more.

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Having been involved in this process once before, Itried to share what happened (the same thing) at the firstplace I had worked that attempted this process. If youdecide to go to a team model, my experience has beento assign rooms in that team to prevent the pitfalls I haveseen with both experiences I have had with this process.

I truly understand and agree with the team concept,but it was difficult both times and at both places I workedthat went to a team model.

Utopia does exist—I have to believe that—and theteamwork concept is ideal, but working it as staff(as I have found at 2 different hospitals) is a difficultmindset change for those nurses who perhaps have notbeen giving as much as others. Planning, education, andstaff involvement are keys to success!—Mary M. Pelton,RN, CEN, Assistant Director, Emergency Services, CarteretGeneral Hospital, Morehead, NC; E-mail: mmpelton@ccgh.org

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