emergency department operational improvements uhc january 27, 2010 cambridge health alliance assaad...
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EMERGENCY DEPARTMENTOPERATIONAL IMPROVEMENTS
UHC
January 27, 2010
Cambridge Health Alliance
Assaad J. Sayah, MD, FACEP
Chief, Emergency Medicine
2
Overview of Cambridge Health Alliance:Provider Network
Hospital: 3 campuses with 24-hour Emergency Services:
– The Cambridge Hospital– Somerville Hospital (7/1/96)– Whidden Memorial Hospital (7/1/01)
Community-based Primary Care and Mental Health Services:
– services at hospital campuses – 18 neighborhood health centers, 4 school-based health centers
CHAPO: Cambridge Health Alliance Physicians Organization
– Employer and contractor for MD services– Physician services organization – provider enrollment, billing,
claiming, malpractice coverage, HR support
3
Overview of Cambridge Health Alliance:Non Provider Components
Network Health- a statewide managed Medicaid health plan
– Medicaid products: 92,785 covered lives Commonwealth Care products: 68,280 covered lives
Public Health:– Includes Cambridge Public Health Department and Institute for
Community Health– Work closely with public health departments in Everett and
Somerville
Alliance Foundation for Community Health (Philanthropy)
Academics:– Teaching affiliations with:
Harvard Medical School Tufts Univ. School of Medicine Harvard School of Public Health Teaching Affiliate
– Training programs in social work, nursing, and occupational/physical therapy
4
Regional Safety Net Provider
Largest proportional provider of uncompensated care in the State. (33% of our service volume) AND (51% Medicaid & 28% Medicare)
Care for uninsured patients from over 257 MA communities
Many patients travel to overcome access-to-care barriers (uninsured or under-insured, culturally and linguistically appropriate care)
Leading state-wide acute hospital provider of inpatient psychiatry
– 10% of the statewide mental health discharges – 33% of statewide mental health free care discharges. – greater than 33% of our patients and 57% of our mental health
patients come from outside our 7-town primary service area
5
Why Change ?
Change in Healthcare environment Change in Healthcare reimbursement No Growth Poor patient satisfaction Inefficiencies
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All MAHosp DB 20K-30K State
N=961 N=205 N=33Cambridge Hospital 7/1/06-9/30/06Waiting time before noticed arrival 3 2 1Helpfulness of first person 3 1 1Personal/Insurance Info 3 1 1
Somerville Hospital 7/1/06-9/30/06Waiting time before noticed arrival 27 17 34Helpfulness of first person 43 28 53Personal/Insurance Info 42 29 59
Historical State
28,979 28,80027,983
29,10028,510 28,155
20,000
22,500
25,000
27,500
30,000
FY02 FY03 FY04 FY05 FY06 FY07Projected
CH Registered ED Visits
FY07 Projected represents the fist 5 months annualized
•Annual visit volume has averaged ~28.5k visits per year
•Through 5 mos, volume is down 2% from the PY
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Essential Elements
Leadership Team– Constitution– Alignment– Commitment– Communication
Administration Support
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ED Vision for the Future
Process StaffingCapital
Investment
•Patient Flow Project•ED Flow•Inpt. Discharges•MD & RN communication between ED and Inpt. Unit•Triage/Registration•Laboratory TAT
•Transfer Leakage
•MD Staffing/Productivity•Nursing•Clinical Support •Administrative•Registration
•ED Information System•Tracking Board•Electronic Medical Record
•ED Front End Redesign•Wireless Bedside Registration
Current State
•Best Practice Patient Satisfaction•Door to Doc (30 mins / 90%)•Increased volume and capacity
Future State (2-3 yrs)
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Staffing
MD Staffing / productivity– Culture– Market analysis– Comp plan– Incentive– Feedback
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$174.06
$198.90
$153.13
CHA Max Non-CHA Avg. CHA Max (Proposed)
2007 Hourly Compensation
•The goal is to close the compensation gap between CHA and competitors
•Recognizing the magnitude of the salary gap, the 2007 proposal is to reduce less than half the gap between the CHA and the rest of the marketplace
Gap
Fully Loaded Hourly Compensation(Includes fringe & excludes malpractice)
Midpoint $176.02
Midpoint Rate $176.021.0 FTE (1,570 Clin Hours) $276,344
Less Fringe ($18,271)
Midpoint of CHA Max & Non CHA Avg. $258,073
Proposed CHA 2007 Max Compensation $255,000
$174.06
CHA Max Non-CHA Avg. CHA Max (Proposed)
111
Total Compensation Market Competitive Experience based BC / BE Reviewed annually
Two Tiered Compensation
Salary WithholdIncorporates:
– Productivity– Quality– Patient Satisfaction– Citizenship
Salary Withhold
Guaranteed Base
Salary
Total Compensation
Total Compensation
Salary Withhold“Performance Bonus”
Guaranteed Base Salary
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Monthly Physician Summary
Partial FY 2006 (9/1/05-6/30/06)Based on actual date of service, not date posted to AR
GoalWork RVU's Per Hour WRVU's MGMA %
Physician Code Total Hours *Pts WRVUs FY06 Pts/Hour WRVU/Pt 1.0 FTE 85th % tile MGMAPhysician 398922 31.00 104 179.00 5.77 3.35 1.72 9,065 8,542 106%Physician 648979 589.00 1,871 3,271.74 5.55 3.18 1.75 8,721 8,542 102%Physician 854235 788.00 2,070 3,962.39 5.03 2.63 1.91 7,895 8,542 92%Physician 576280 555.50 1,268 2,522.03 4.54 2.28 1.99 7,128 8,542 83%Physician 755663 808.50 2,013 3,630.99 4.49 2.49 1.80 7,051 8,542 83%Physician 659459 92.00 200 402.39 4.37 2.17 2.01 6,867 8,542 80%Physician 874906 72.00 176 313.20 4.35 2.44 1.78 6,830 8,542 80%Physician 555917 692.00 1,674 2,939.17 4.25 2.42 1.76 6,668 8,542 78%Physician 640499 1,160.50 2,689 4,894.24 4.22 2.32 1.82 6,621 8,542 78%Physician 88324 1,066.50 2,417 4,464.97 4.19 2.27 1.85 6,573 8,542 77%Physician 549321 998.00 2,002 3,616.91 3.62 2.01 1.81 5,690 8,542 67%Physician 870211 257.00 598 913.43 3.55 2.33 1.53 5,580 8,542 65%Physician 398703 96.00 186 331.37 3.45 1.94 1.78 5,419 8,542 63%Physician 292250 1,542.25 2,450 4,728.41 3.07 1.59 1.93 4,813 8,542 56%Physician 54992 1,232.00 1,948 3,151.33 2.56 1.58 1.62 4,016 8,542 47%Physician 66271 69.50 80 155.84 2.24 1.15 1.95 3,520 8,542 41%Physician 339564 27.00 30 53.99 2.00 1.11 1.80 3,139 8,542 37%*99281-99285, 99291
+ 1 SD 5.04 2.81 1.94 7,916 Mean (Excluding Night MD) 3.94 2.19 1.81 6,189 8,542 72%
- 1 SD 2.84 1.56 1.68 4,462
Weighted Avg. 3.92 2.16 1.82 6,159 8,542 72%
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Quality & PT Satisfaction
Timely Chart Completion
CHA-wide Initiatives (e.g. CAP Antibiotic Time)
Chart Review for clinical compliance and appropriateness
Pain Management
PT Flow Metrics /Throughput times
House Staff Evaluations
Documentation of Conscious Sedation
Incident Review
Press Ganey by Physician
PT Satisfaction (by measure of Complaints & Compliments)
Restraints
Other
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Citizenship
Staff Meeting Attendance Committee Participation & Leadership Team Player (e.g. shift coverage & flexibility) Administrative Duties & Scholarly Activities Community Involvement Staff Compliments & Concerns Compliance with administrative initiatives Other non-required activities which contribute to
Emergency Medicine Other
15
Staffing
Nursing / Other Culture Support
16
ED Visits
Current IncrementalCH P
ropose
d
25,
001
to 3
0,00
0
Authorized Requested TotalFTEs FTEs FTEs
Total ED Nursing Staff (LPN + RN) 19.46 2.65 22.11 24.50
Staff Nurse (RN) 17.36 4.75 22.11 Mean 23.10
Min 14.00
Max 37.10
Std. Dev. 5.80
No. of EDs 33
Staff Nurse (LPN) 2.10 (2.10) - Mean 1.40
Min -
Max 12.00
Std. Dev. 2.30
No. of EDs 32
Nursing Assistant/Aide/Tech/EMT 5.34 1.68 7.02 Mean 7.00
Min -
Max 21.50
Std. Dev. 3.90
No. of EDs 32 - Unit Secretary 3.14 1.07 4.21 Mean 4.50
Min -
Max 13.50
Std. Dev. 2.50
No. of EDs 29
CH Nursing & Support Staff Benchmarks
2005 ENA Emergency Department Benchmark Survey
Patient Flow Project
System Project Teams
Cambridge Health Alliance
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Patient Flow is a Hospital-Wide Concern
Every hospital unit has a part to play—the ED cannot solve the flow problem alone.
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Project Charter
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Patient Flow Project Goals
Improve patient flow on all 3 campuses Do so in a timely, safe, effective, efficient, and
patient-centered manner Implement best practices Utilize improvement methodologies, tools, and
measures Utilize a multi-disciplinary, multi-campus single
solution approach Engage hospital staff
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Structure
Identify common issues across the system Consolidate various campus teams working
on the same topic Multiple disciplines (MD,RN, Support Staff) Coordination among the teams Avoid redundant work Develop aggressive timelines for deliverables
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Focus is Across the ContinuumFocus is Across the Continuum
22
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Fundamental Mission of Teams
Team Mission
ED Patient Flow Minimize time patients spend in the ED through the application of “best practices”
Laboratory Turnaround Time
Manage the ordering, collecting, testing, and verification of lab work through improved and standardized procedures
No Delay Nurse Report
Transport admitted patients to inpatient unit within 30 minutes of ED nurse giving report
Physician Admitting Orders
Expedite completion of admitting orders for admitted ED patients
Inpatient Discharges
Decrease length of stay through effective discharge planning activities
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Project Methodology
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Recommendations
Change ED flow– Patient partner– Mini Registration– Triage patients in less than or equal to national
average of 7 minutes ESI
– Bedside Registration– Rapid assessment– Maximization of bed utilization
Culture change
– Admissions to virtual ED beds
26
Recommendations
Redefining roles of staff– RNs and PAR IIs draw labs– Charge Nurse Role– RN’s discharging patients– Create MD Order Sets
This has streamlined order entry
– Create RN Order Sets (MD Standing Orders)
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Recommendations
IT:– EPIC / ASAP– Dictation– PACS– MUSE
System Integration:– PCP Initial notification– Heads up from PCP and EMS– Medical record access– Access to ED workup– Referral
Standardization of:– P &P, Guidelines– ED documents– Equipment– Material
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Recommendations
Process to improve quality of careProcess to improve quality of care Diagnostics:Diagnostics:
– Order setsOrder sets– Pneumatic Tubes in all EDs– Labeling lab specimens with a barcode labelLabeling lab specimens with a barcode label– Receiving the specimens in the lab using a barcode wandReceiving the specimens in the lab using a barcode wand
Throughput:Throughput:– Early identification of admissions– Maximize utilization of all inpatient capacityMaximize utilization of all inpatient capacity– Early assignment of inpatient beds– Early handoff to the admitting service– Faxing nursing report on admitted patients– Early transport to the floors– Escalation process
Back up Code Help
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All MAHosp DB 20K-30K State
N=961 N=205 N=33Cambridge Hospital 7/1/06-9/30/06Waiting time before noticed arrival 3 2 1Helpfulness of first person 3 1 1Personal/Insurance Info 3 1 1
Somerville Hospital 7/1/06-9/30/06Waiting time before noticed arrival 27 17 34Helpfulness of first person 43 28 53Personal/Insurance Info 42 29 59
ED Patient Partner
ED Patient Access Representative– Ambassador to patients in the waiting area– Mini registration to facilitate patient flow
Part of a response to deficiencies in Press Ganey patient satisfaction scores related to arrival and personal issues
Press Ganey Percentile Rank
30
Rapid Assessment Overview
The purpose of the unit is to facilitate rapid assessment and treatment at the point of arrival in the Emergency Department
Combine Express Care and Triage to form a Rapid Assessment Unit (RA)
Relocate Registration inside the ED (Promotes bedside registration)
Combine nursing resources from Express Care and Triage – offers the ability to care for multiple patients at once
Move Physician Assistant to RA. – The role of the PA is to rapidly assess and when applicable,
treat and release the patient without entering the Acute ED. – May also play a role in the initial assessment and ordering of
diagnostics for acute patients.
31
ED Transfers
EMERGENCY DEPARTMENT PHYSICIAN COMPLETES FORM
Patient Transferred To: _____________________ Date: _________ Diagnosis: ______________
REASON FOR TRANSFER (check all that apply)
Bed Availability
No ICU M/S Tele bed available at home institution.
No ICU M/S Tele bed available at TCH SH WH
Bed Availability Confirmed with Off Shift Manager (OSM)
Specialty Care Availability
Specialty Care Available at Home Institution Yes No CHA Yes No
Specialty Need: Cardiac Cath. Detox ENT Neurology OB/GYN Ophthalmology Peds Psychiatry Surgery: General Surg. Hand Neurosurgery Orthopedics Plastic Trauma Urology Vascular Imaging: CT MRI Ultrasound Other Specialty Need (please explain) _________________________________ _________________________________________________________________ _________________________________________________________________
Patient / Physician Preference
Patient requested to go to receiving institution.
Patient had previous care at receiving institution.
PCP ____________________ requested transfer to the receiving institution. PCP Name
Consultant ____________________ requested transfer to the receiving institution. Consultant Name
Other Information Relevant to the Transfer
___________________________________ __________________ __________________ CLINICIAN DATE APPROXIMATE TRANSFER TIME
Transfer Form Developed
Monitor External ED Transfers (100% case review by ED Site Chiefs)
Understand Reasons for Transfer
Bed Availability
Specialty Availability
Patient Preference
PCP Preference
Other
Create a feedback tool to improve services and target opportunities to reduce system leakage
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If one (1) or more symptoms are checked, determine if ordering a chest x-ray is appropriate by assessing the additional risk factors.
If no symptoms are checked, stop here and care for patient according to standard protocols.
Additional Risk Factors Circle Score
History
Men (For Men enter Age in years)
Women (For Women enter Age in years minus 10)
Nursing Home Resident +10
Neoplastic Disease (active or recently diagnosed) +30
Liver Disease (chronic) +20
Congestive Heart Failure +10
Cerebrovascular Disease (stroke or TIA) +10
Renal Disease +10
Physical Exam Findings
Altered Mental Status (acute) +20
Respiration ≥ 30/minute +20
Systolic BP <90 mm Hg or Diastolic BP < 60 mm Hg +20
Temp <35 C or ≥40 C (<95 F or ≥104 F) +15
Pulse ≥125/minute +10
HIS
TO
RY
& P
HY
SIC
AL
02 Sat < 90% +10 Nurse Signature ______________________________________________________________ Date ________________________________ Time ________________________________
Total Hx & PE
Score
Order CXR if score is
70* or greater
Revised 11/1/06 * The ED physician may order a CXR for patients scoring less than 70.
Check All Presenting Symptoms That Apply
Fever / Chills Shortness of breath
Cough Change in mental status
Chest discomfort Pneumonia suspect
Emergency Department Guidance for Ordering Chest X-Rays at Triage
For use with patients presenting with respiratory distress or suspected pneumonia
Community Acquired Pneumonia
Core Measures: In order to improve compliance with “Community Acquired Pneumonia” core measures, we developed a triage patient risk scoring process for rapid identification and management of CAP patients
Emergency Department Information System
Cambridge Health Alliance
EPIC ASAPEPIC ASAP
34
EPIC ASAP Implementation
The Phase 1 Implementation includes:– Electronic Triage– Tracking Board– Electronic Discharge Documentation / Prescriptions
Go Live Dates– TCH went live May, 2008– SH, July 2008– WH, November 2008
35
Triage & Discharge
Triage Meditech interface of arrival information, chief
complaints, and other patient data Nurses enter all triage documentation into
ASAP which makes it available to the entire treatment team
Discharge Documentation Diagnosis and Disposition Prescriptions Discharge Instructions
36
Tracking Board
Enables the ED to track and record all patient activities throughout their ED Visit beginning with registration through departure from the ED
As the patient status changes (waiting for bed, waiting for provider, waiting for reevaluation, etc.) color codes are assigned to alert staff
Results Reporting – Lab & Radiology Orders for POC testing, urine collection, EKG
request, and safety measures are flagged on the tracking board and checked off as completed
37
37
Tracking Board
38
38
ED Manager View
39
39
ED Dashboard
40
Outcomes
Results are overwhelming– ED TAT reduced – A 70% reduction in the number of patients leaving without being
seen – Patients have noticed a difference– Press Ganey– The reception area has remained empty during peak times– “This was the quickest emergency room visit I've ever had”
ED Staff feels like the ED is “calmer” – less chaotic 100% of patients are registered at bedside Budget neutral
– Reallocated existing staff and space– Zero up front capital costs
41
ED Ambulance Diversion
0
10
20
30
40
50
60
70
80
Feb-06
Mar-06
Apr-06
May-06
Jun-06
Jul-06
Aug-06
Sep-06
Oct-06
Nov-06
Dec-06
Jan-07
TCH SH WMH Total CHA
Total Hours on Diversion
Ambulance diversion is not good for our patients CHA has seen steady decreases in the number of hours on
diversion Diversion has been eliminated at the Cambridge and Somerville
campuses and has been significantly reduced at the Whidden
42
ED Diversion Hours / % of Time on Diversion
0.0%0.0%0.0%0.0%0.0%0.0%0.0%0.0%0.0%
8.5%
4.7%
3.2%3.5%2.8%
1.9%
020406080
100120140160180200
Ho
urs
on
Div
ersi
on
0.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%8.0%9.0%
% o
f T
ime
on
Div
ersi
on
Total Time % Time
43
ED Turnaround Time
140
150
160
170
180
190
Min
s
44
ED Press Ganey Patient Satisfaction Overall Mean Score
84.4085.60
78.6077.00
80.90
85.00
78.20
76.1075.10
79.9081.00
77.4078.90
75.90
68.0070.0072.0074.0076.0078.0080.0082.0084.0086.0088.00
Q1FY06
Q2FY06
Q3FY06
Q4FY06
Q1FY07
Q2FY07
Q3FY07
Q4FY07
Q1FY08
Q2FY08
Q3FY08
Q4FY08
Q1FY09
Q2FY09
Overall Mean Peer Group 50th %tile
45
ED Left Without Being Seen Rate (%)
0.97%
4.04%
2.38%
1.33%
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
FY06 FY07 FY08 FY09 YTD Feb
46
28,979 28,80027,983
29,10028,510 28,155
20,000
22,500
25,000
27,500
30,000
FY02 FY03 FY04 FY05 FY06 FY07Projected
Historical Volume Trends
CH Registered ED Visits
FY07 Projected represents the fist 5 months annualized
•Annual visit volume has averaged ~28.5k visits per year
•Through 5 mos, volume is down 2% from the PY
47
ED Visits & Admissions
28,481
31,865
30,341
28,796
2,8923,123
3,155
3,687
26,000
27,000
28,000
29,000
30,000
31,000
32,000
33,000
FY06 FY07 FY08 FY09
Vis
its
2,000
2,500
3,000
3,500
4,000
4,500
5,000
ED
Ad
mis
sio
ns
Registered Visits ED Admissions
48
Average ED Sensitive Quality Core Measures Indicator Rates
AMI ( ASA on arrival, B Blocker on arrival) CAP (Abx within 4 hours, BC prior to Abx)
82% 81%
95% 94% 96% 94% 94% 95%99%
97% 97%
50%
60%
70%
80%
90%
100%
Q4FY06
Q1FY07
Q2FY07
Q3FY07
Q4FY07
Q1FYO8
Q2FY08
Q3FY08
Q4FY08
Q1FY09
Q2FY09
49
Challenges
Sustain improvements Keep the staff engaged Continue to improve the system Output output output….
Questions
Cambridge Health Alliance