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

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)

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

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

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

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

“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)

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)

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”

Our Professional Practice Model

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

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”

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

Implement adult and pediatric “acute carts”

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)

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

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

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

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

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

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

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

Communicate, Communicate… Never under estimate the value of communication

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

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

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

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

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

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.

It is all about the ER team

Focus on the “Patient” not on ourselves