1. Internal Medicine Executive Committee
Improving Emergency Department Patient Satisfaction
IHS Spring Symposium 2010

2. Our motivation to change
Press Ganey scores lowest in IHS
High Nursing & Management turnover
Problems with image within our hospital and the community
43% Market Share (2006)

5. Situation with Physicians
Contract due to be changed
No raises in pay for 4 years
Not much interest or respect for Press-Ganey

6. Physician Reimbursement What we tried
Align goals – we want patients satisfied; physicians thrive on competition
A bonus “pool” was developed
Physicians earn shares in pool by getting higher individual Press-Ganey scores
Pool can enlarge based on overall ER score

7. Physician Reimbursement What Happened?
First two quarters only one physician had shares in pool – and got all the $$$$
Since then all physicians have shared in pool on at least one occasion
Awaiting the first quarter with all physicians sharing

8. 2009 Emergency Department Strategic Plan
Deliver Patient Centered Care
Implement Shared Leadership
Involve and engage staff in change
Develop Standardized, Efficient Processes
Use data to drive change

9. “Shared leadership is about having a voice – being informed, heard, and included in decision making.”
Trusting atmosphere allows nurses to feel safe and supported in their decisions
Rules do not impede delivery of patient care
Opportunity for professional nurses to participate in decisions that affect their practice and work environments
Moore and Hutchison (2007)

10. Why Shared Leadership? Develops “dedicated” employees
Stay with the organization
Improve patient outcomes, increase patient safety and reduce risk
Are “owners” of the organization and deliver improved service to all customers
Press Ganey (2010)

11. Shared Leadership Implementation Our First Steps:
Professional practice model developed
Front line staff chosen and mentored to lead teams
ED physicians champion each team
All ED staff involved in a committee
We know that:
Front line staff “Know how to do it Best”

12. Our Professional Practice Model

13. Shared Leadership Implementation Our Next Steps:
Teach staff to apply performance improvement & lean principles
Teach staff to continually evaluate process
“Complain about things that matter”
“Status quo” and “The way we have always done it” are unacceptable

14. Deliver Patient Centered Care
Patients taken immediately to bed if bed available (Direct Rooming)
NO STOP (DELAY) IN TRIAGE!
Triage is a “process” not a “location”
Bedside Registration
“Patients come to see the Physician”

15. Standardize Patient Care
“Right things, right place, right time, every time.”
Nursing documentation bundled at bedside
Room & Supply Standardization
Purchased additional point of care equipment
Thermometers, BP monitors, pulse oximetry
Standardize equipment in all rooms

16. Implement adult and pediatric “acute carts”

17. Standardize Patient Care
ED paper order set developed
Decreases verbal orders
Available in rooms for immediate use
Order sets built into Care Cast allowing easy/accurate order entry
Priority lists built in Care Cast (Lab & Radiology)

18. Standardize Patient Care
ISTAT point of care testing implemented
Laboratory tube standardization and draw bag implementation
Portable PACs available for physicians

19. Improve Patient Flow “ED Alert” implementation
Alert developed and called over head to alert inpatient areas, lab, radiology, and housekeeping of emergency department capacity
Facilitates flow to inpatient areas when ER overbooked
Creates hospital-wide teamwork

20. Improve Communication
Communication within the department
Communication outside our department
Working with other nursing & ancillary departments
Building relationships with “Customers”

21. Lessons Learned Change is challenging and not without pain
Change is Disruptive
Not everyone likes every change
Management can have difficulty “keeping up” with staff and physicians

22. Lessons Learned Evidenced based practice works.
Early successes build confidence
Build processes to match practice
Make the right thing to do the easiest thing to do
Re-evaluate every change for effectiveness and value

23. Lessons Learned Short, point of care meetings are valuable.
Well organized, action item agendas are vital to formal meetings.
Everyone has a voice.
Physicians do “CARE”. They work here every day also

24. Lessons Learned
“Lean and clean” is a great way to enhance the care environment without resources (paint, cleaning, and reorganization are cheap and great motivation)
Rummaging for equipment
Finding alternative sources of funding is key

25. Communicate, Communicate…
Never under estimate the value of communication

26. Data Drives Change Transparency of Data Teach staff to interpret data
Show all data-The good with the bad
Teach staff to interpret data
Keep data current and visible for all to see
Internal and external customers

27. Staff are interested in data
Keep results on a visible board for all to see

28. Staff are interested in data Keep results on a visible board for all to see

29. Staffing Below Benchmarks
Making meetings work:
Approximately 40 staff hours of formal meetings a month (8 hours-5 staff each mtg)
Small, quick “point of care meetings”
ED Staffing Benchmarks
Emergency Department
FYTD Hours
UOS (2009)
50th Percentile
2.51
2.80

30. Return on Investment January 2010 Median Length of Stay in ED
71% of patients seen by physician < 30 minutes
93% of patients seen by physician < 60 minutes
Median Length of Stay in ED
103 minutes
15% increase in visits over past 2 years

31. Because of an improvement in flow we are seeing patients more rapidly, decreasing patients that leave unhappy and AMA, and therefore decreasing the risk to St. Luke’s while increasing revenue.

34. It is all about the ER team

35. Focus on the “Patient” not on ourselves