Transforming the Emergency Department Experience · 2018-04-14 · •Discuss how interdisciplinary teamwork within the organization can positively impact the Emergency Department

Transforming the Emergency Department Experience

Northwestern Memorial Hospital, Chicago IL

Michael Schmidt, MD, FACEPAssociate Chief Medical OfficerAssistant Professor of Emergency Medicine, Northwestern University Feinberg School of Medicine, Department of Emergency Medicine

Eileen Brassil, BSN, RN, CENEmergency Department Practice Manager

Tiffani Darling, MNAManager Patient Experience

Session Objectives

• Understand how implementing a care-at-arrival process and communication model impacts the patient experience

• Learn how to involve resident physicians in patient experience improvement efforts

• Discuss how interdisciplinary teamwork within the organization can positively impact the Emergency Department patient experience

2

Session Objectives

• Share our journey (in progress)

• Outline improvements made

• Discuss both past and present barriers

• Describe a desired future state

3

Continued

Background

4

Northwestern Memorial Healthcare Overview: Patients First

Facilities & Locations System Overview

NMH & NLFH: 1,011 Beds

NMG: 1,000+ Physicians

23 Satellite Ambulatory Locations

Nationally Recognized Leader for Quality and Safety

Primary Clinical Affiliate of Top 20 Medical School-Northwestern University’s Feinberg School of Medicine

# 6 Hospital on the 2013-2014 US News & World Report Honor Roll of Top Hospitals

Over 11,000 employees

Chicago’s Most Preferred Hospital

Feinberg and Galter Pavilions

Prentice Women’s Hospital

Northwestern Lake Forest Hospital

259 E. Erie Building

Glenview (Primary & Immediate Care)

•Lindenhurst•Imaging

•Grayslake•Internal Medicine•Surgery Center•Dermatology•Sports Medicine

•Libertyville•Internal Medicine•Family Practice

•NLFH•Internal Medicine•Gynecology

•Deerfield•Internal Medicine•Dermatology•Immediate Care

•Highland Park•Internal Medicine

•Glenview•Internal Medicine•Speciaists•Pediatrics•Immediate Care

•Lakeview•Internal Medicine•Immediate Care•NMH Radiology

•Loop•Executive Health•Boeing•CNA

•NMPG Streeterville•Imaging

•OB/Gyn

•NMPG Integrative Medicine•Internal Medicine•Family Practice

•Lincoln Park•Dermatology•Pediatrics•Internal Medicine

•Bucktown/ Wicker Park •Internal Medicine•NMH Radiology

North Market

Chicago

Recognized for Excellence

AA+

Aa2

5

Northwestern Memorial Hospital Emergency Department

• Large, urban, academic emergency department

• Level 1 Trauma Center

• 57 patient care bays

• 52 full and part time attendings

• 4 year EM residency with 48 total residents

• 135 Registered Nurses

• 38 Emergency Department Assistants (EDAs)

• Primary teaching hospital for Northwestern University Feinberg School of Medicine

• 150 4th year medical students per year

6

NMH Emergency Department VisionTo be the preeminent academic emergency department in the country by achieving top decile performance in patient experience, operations and patient quality and safety.

7

ED Closures across the United States

8

Date of download: 3/18/2014Copyright © 2014 American Medical

Association. All rights reserved.

From: Factors Associated With Closures of Emergency Departments in the United States

JAMA. 2011;305(19):1978-1985. doi:10.1001/jama.2011.620

Figure Legend:

NMH Emergency Department Volumes

• 20% of ED patients are admitted

• Over 40% of NMH inpatients come through the ED

• 15-20% of ED patients arrive by ambulance

61,440

66,169 68,092 67,299

72,000

76,400

81,100 83,269

84,519 84,714

87,821 88,861

87,254

50,000

55,000

60,000

65,000

70,000

75,000

80,000

85,000

90,000

95,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

ED Patient Volumes by Year

NMH ED Challenges

• Growing volumes

• Hospital overcrowding

• Increasing rates of LWBS

• Decreasing patient satisfaction

10

64.863.1

58.3

77

61

38

30

35

40

45

50

55

60

65

70

75

80

FY10 FY11 FY12

% V

ery

Go

od

Re

spo

nse

s

NMH ED Likelihood to Recommend

NMH ED LTR UHC Percentile Ranking

3.3%

4.0%

4.7%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

FY10 FY11 FY12

% o

f LW

BS

visi

ts

LWBS

3.90

4.334.77

2.00

2.50

3.00

3.50

4.00

4.50

5.00

FY10 FY11 FY12

ED Median LOS (hrs)

Implementing the Care at Arrival Process

11

ED Leadership

• Came together as one team

• Re-affirmed patient centered mission of ED

• Established common goals

• Focused on a high impact initiative to globally improve care and the patient experience

• Embedded motivated leaders that were willing to be innovative

12

A Critical Component

Internal Focus For Improvements

• Inpatient boarding?

• Delays in diagnostic testing?

• Psychiatric holds?

• THE WAITING ROOM

13

What was under our control?

Root Causes of Delays

Process Step Potential for delay

Triage 1 •Waiting in line for T1• Patient does not know about the T1 process and sits down

Registration •Waiting in line for registration•Volunteers completing registration duties

Triage 2 •Wait in line for T2•Practice variation of the T2 nurses•No way to prioritize queue for T2•Not using the ESI algorithm

Post Triage 2 •Waiting after T2 when all ED beds are full•Patient doesn’t match placement criteria of space•Waiting after T2 when ED is not full to staff constraints/ reluctance•Culture that every patient goes back after T2 •Transportation

Vision: Achievement of the Best Patient Experience, no matter the path nor the location. It starts with a singular focus on Care At Arrival; this vision sustains, motivates, and energizes us as we provide collaborative and responsive care early and ensure quality, safety, efficiency and

compassion throughout the patient stay.

Care-At-Arrival (CAA) Model

Re-defined Triage Staff Roles & Responsibilities

INTAKE (Inflow) TREATMENT DISCHARGE (Outflow)

Intake 1 Nurse

Intake 2 Nurse

MD-CAA

Charge Nurse

Care at Arrival (CAA) Model

Responsible for Inflow and ED Bay Placement Based on Quick Look

Responsible for Rapid Triage & Care Initiation in Coordination w/ MD-CAA

Responsible for Rapid Medical Assessment, Care Initiation & Flow Coordination

Responsible for Patient Outflow and Team Support; Bed Optimization in ED Bays

CAA ED Patient Flow

*Under Age 40 w/pre-selected criteria?

(Flank pain, r/o appy, chest pain, r/o dvt, BHT

w/o LOC, UTI, Mild Asthma, Syncope )

Patient Enters the

ED

Intake 1

Bay?

Critical?

Intake 2

RN Triage, MD Eval,

Care Begins

DischargeMD Post

ProcessingED Bay Queue or T4

Waiting Area ED Bay

Admit ED Bay Discharge

ED Bay/

Definite Care

(Main, Mezz)

ED Bay/

Definite Care

Short waitIntake 2

Queue Area

Yes

Yes

No

Yes

Intake 2

Available?

EMS call or arrival

( T4, Main, Mezz)

No

No

(T4, Main, Mezz)

No

*No

Yes

Meeting Patients’ Expectations: Communicating the Process

Intake 1 RN

•Always introduce yourself w/Greeting

•Explain the expected flow and process to the patient

•Introduce the next care provider when possible

•Explain Next Step in Care Plan

Intake 2 RN

•Always introduce yourself and qualify your self as the point-person

•Explain that care is starting now

•Explain procedures to be performed and why

•Explain the possibility of redundant questions

•Introduce the next care provider

•Explain Next Step in Care Plan

Intake EDA

•Always introduce yourself

•Explain activities as you do them

•Explain the next steps and say who will be performing them

EKG EDA

•Always introduce yourself

•Explain the EKG process

•Explain that the doctor will review the results immediately

Intake MD

•Always introduce yourself

•Explain the care plan

Transporters

•Always introduce yourself

•Explain why the patient is going to another care space

•Explain next steps (i.e. the patient will be waiting in a chair for the next available care space)

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• CAA Must Provide Ownership, Expectation Setting, and Explanation of Care Delivery

• All members of the team play a key role in communicating the process

Three Phase Approach: Evolution of a Model

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Transforming Emergency Care Video

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Comparative Metrics

Timeframe: Summer Peak Volume Months May 1 - August 31

2011% Δ

'11-12 2012% Δ

'12-13 2013% Δ

'11-13CAA Coverage Days/Week 0 3 5

Total ED Patient Volume 31,104 - 1% 30,845 - 1% 30,537 - 1.8%

LWBS-% 4.6% + 7% 4.9% - 29% 3.5% - 25%

Total Patients (Seen & Treated) 29,670 - 1% 29,330 + 1% 29,478 - 0.6%

Door-to-Doc [mins] (Median) 44 + 9% 48 - 19% 39 - 11%

Door-to-Doc: ESI 2 37 + 5% 39 - 23% 30 - 19%

% seen within 30 min 43% - 3% 42% + 20% 50% + 16%

Door-to-Doc: ESI 3 58 + 16% 67 - 24% 51 - 12%

LOS-Overall [hrs] (Median) 4.7 + 6% 5.0 - 7% 4.6 - 1%

LOS-Admit (Median) 6.6 + 3% 6.8 - 8% 6.3 - 5%

LOS-Discharge (Median) 3.7 + 9% 4.0 - 5% 3.8 + 4%

Door-to-Pain Meds (Pain > 4) [mins] (Median) 46 - 4% 44 + 2% 45 - 2%

Door-to-EKG Median [mins] (Median) 14 - 21% 11 - 27% 8 - 43%

Door-to-EKG (Stdev) 19 - 29% 13 + 1% 13 - 28%

Patient Satisfaction (% Very Good Responses) 55% + 4% 57% + 2% 58% + 5%

Impact of Care at Arrival on Performance Metrics

Achieved Highest Patient Satisfaction in 5 Years!All sections and questions improved over prior year

Survey Question Change

Overall rating ER care 8.0Likelihood of recommending 7.4Deg hosp staff worked as a team 7.1Staff cared about you as person 6.1Privacy during pers/insur info 6.0Staff sensitivity to your needs 5.9Overall appearance of E.R. dept. 5.9Ease giving pers/insur info 5.5Staff identifies themselves 5.3Waiting time before lab procedures 4.9How well pain was controlled 4.7Adequacy of info to family/friends 4.7Courtesy during pers/insur info 4.7Helpfulness of triage nurse 4.5Courtesy shown family/friends 4.3Nurses attention to your needs 4.1Waiting time to see doctor 4.0Waiting time to treatment area 3.9Technical skill of nurses 3.8

Survey Question Change

Informed about delays 3.8Waiting time before noticed arrival 3.7Let family/friend be with you 3.6Nurse took time to listen 3.5Courtesy of person who took blood 3.4Nurses informative re treatments 3.4Doctors courtesy 3.3Information about home care 3.2Nurses concern for privacy 3.0Nurses courtesy 2.7Concern blood draw comfort 2.7Comfort of waiting area 2.6Doctor took time to listen 2.6Concern for comfort radiology test 2.5Doctors concern for comfort 2.4Courtesy of radiology staff 2.3Security staff 1.7Doctor informative re treatment 1.4Waiting time for radiology test 0.1

58.3

65.7

38

51

30

35

40

45

50

55

60

65

70

75

FY12 FY13

% V

ery

Go

od

Re

spo

nse

s

NMH ED Likelihood to Recommend Trending by Fiscal Year

NMH ED LTR UHC Percentile Ranking

72.7 UHC Top Decile

Impact on Caregiver Engagement and Teamwork

• Achieved top decile for teamwork within unit on 2013 Patient Safety Culture survey

Highest rated domain on survey

• Overall Safety Culture grade improved 11 percentage points from 2011- 2013

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As measured through Patient Safety Culture Survey

Top Decile Performance for Teamwork Within Unit

AHRQ 90TH PERCENTILE

70 80 90 100

Measured by AHRQ

EDNMH

AHRQ ED AVE

2013 Patient Safety

Culture Survey Results

Excellent + Very Good

ED 2013: 71%ED 2011: 60%ED 2008: 47%

AHRQ ED 2012: 70%NMH: 66%

Resident Engagement in Satisfaction Efforts

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ED Residency Program Overview

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• Four-year residency program

• Large diversity in clinical programs

• 48 ED residents in FY 2014

• Residents play vital role in patient care and satisfaction

Engaging Residents in Patient Satisfaction

• Added resident specific physician questions to ED survey

• A.I.D.E.T. ® communication training during fall resident retreat

• Monthly distribution of department scores and comments

• Quarterly distribution of results by resident - recognition of high performers

• Standing topic on monthly meeting agenda

• PG scores and comments included on the 6-month evaluation reports

25StuderGroup. Acknowledge, Introduce, Duration, Explanation, and Thank You. http://www.studergroup.com/aidet.

ED Resident Physician Survey Questions

26

Resident and Attending Performance

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Residents outperformed Attending physicians on all doctor questions

65.4

69.8

67.3

62.1 62.3

68.2

71.3

69.7

65.9 65.8

70.6

74.9

70.9

67.968.8

50

55

60

65

70

75

Doctors section score Courtesy Took time to Listen Informative retreatment

Concern for comfort

% V

ery

Go

od

Res

po

nse

s

FY13 ED Physician Questions by Attending and Resident

Attendings(n=1816)

Residents(n=1669)

FY13 Goal UHC Top Decile

Reporting by Resident Physician• Attribution method:

Attending physician= discharge physician of record

Resident physician=1. The resident who wrote the

encounter note in the MR

2. If a resident did not write note, attribution is based on FirstNet documentation

3. If neither, "UNKNOWN" is attributed to the encounter.

• Use n ≥ 5 rule

• Distributed quarterly, rolling FYTD score

• ED dept. leadership receives un-blinded scores

• All comments distributed un-blinded

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32.9%42.9%

48.7%50.0%

52.1%53.6%54.0%54.2%

55.8%56.3%56.6%

58.8%59.9%60.0%60.3%60.5%60.8%61.0%

62.7%63.1%

64.5%64.7%

65.5%65.7%66.0%66.0%66.1%66.3%66.4%66.7%66.7%67.2%67.8%68.0%68.3%68.4%68.8%69.0%

70.6%72.7%72.9%

73.7%74.8%75.0%75.0%75.0%

76.0%76.5%

77.3%77.4%

78.4%78.8%79.2%79.2%

80.0%80.6%80.9%

81.9%82.3%82.5%

83.9%84.4%

87.0%87.5%87.5%

90.0%91.7%

100.0%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

D2D1E8E4D8F6G3C3

UHC…C10D7F5F2F9F7E5

D10ED…B4

UHC…B7

F10C9E2C8G1B2A3D5D9C1B6A2B5

% Very Good Responses

FY13 ED Doctors Section Score - Resident Questions Only

Interdisciplinary Teamwork

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ED Patient Experience Interdisciplinary Workgroup

Workgroup Objectives:

• Create a sense of teamwork and ownership from all parties that contact patients in the ED

• Share ideas and feedback

• Monitor performance and trends

• Identify and prioritize opportunities

• Create and implement improvement plans

• Celebrate and recognize performance

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Working together as a team to improve our care and service

Patients and

Families

Registration

EDAs

Lab and Radiology

Security

Social WorkPsychiatry

Follow Up Care

Physicians

Nurses

Example of Projects by ED Workgroup

• Created ED Team Point of Contact List

• Updated Urgent Care info. on website

• Trained Security to provide information on wait times

• Implement process to better disperse info. to team on wait times especially when long delays or equipment failures

• Implement process for EDA comfort rounds in triage and care spaces

• Created and distributed CT, Lab, and Imaging “Hot Sheets”

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Future State

32

Patient-Centered ED Care

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THE FUTURE NMH ED

Patient-centered care models where providers, technology, services and information flow around the patient.

Exams & Procedures

Real-timeupdates

Consultants

Results Waiting

Update

Expand the Care at Arrival Model

34

THE FUTURE NMH ED

Addressing pain, comfort and diagnostic needs of the sick with care initiation upon entry

Comfortable evaluation space

ED Psych

ED Bay

CAA/Fast Track“Vertical Space”

Diagnostic Evaluation

Care Coordination: Inpatient

35

THE FUTURE NMH ED

Improve patient experience and reduce inpatient boarding by facilitating communication across NMH departments, creating better systems and more efficient processes

Care Coordination: Pre-Arrival and Post-Discharge

36

THE FUTURE NMH ED

Use valuable information to anticipate needs prior to arrival

Connect patients to the right care that will keep them healthier

Reduce avoidable visits (e.g., intensive case management)

Push health updates and clinical information to patients and providers through electronic patient portals, better discharge education, and improved communication tools with providers

Achieving Our Vision

Reliable and Efficient Processes

that achieve top decile throughput and performance metrics in length of stay, LWBS and patient experience

Capital Investment

to provide optimal, comfortable space that enables efficient operational process improvement designs and delivers NM level care in the right environment

Collaborative Partnership

across teams, departments, and external stakeholders to promote the Patients First mission

37

We must provide:

1

2

3

Thank You for Letting us Share our Story

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Questions & Discussion

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