EMERGENCY DEPARTMENT OPERATIONAL IMPROVEMENTS

1. EMERGENCY DEPARTMENTOPERATIONAL IMPROVEMENTS UHC January 27, 2010 Assaad J. Sayah, MD, FACEP Chief, Emergency Medicine Cambridge Health Alliance

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 carein 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

6. Historical State CH Registered ED Visits • Annual visit volume has averaged ~28.5k visits per year • Through 5 mos, volume is down 2% from the PY FY07 Projected represents the fist 5 months annualized

7. Essential Elements • Leadership Team • Constitution • Alignment • Commitment • Communication • Administration Support

8. ED Vision for the Future Current State Capital Investment Process Staffing • ED Information System • Tracking Board • Electronic Medical Record • ED Front End Redesign • Wireless Bedside Registration • 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 Future State (2-3 yrs) • Best Practice Patient Satisfaction • Door to Doc (30 mins / 90%) • Increased volume and capacity

9. Staffing • MD Staffing / productivity • Culture • Market analysis • Comp plan • Incentive • Feedback

10. 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 Fully Loaded Hourly Compensation (Includes fringe & excludes malpractice) Gap Midpoint $176.02

11. Two Tiered Compensation Total Compensation Guaranteed Base Salary Salary Withhold “Performance Bonus” Total Compensation • Market Competitive • Experience based • BC / BE • Reviewed annually Salary Withhold Incorporates: • Productivity • Quality • Patient Satisfaction • Citizenship Salary Withhold Guaranteed Base Salary Total Compensation

12. Monthly Physician Summary

13. 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

14. 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. CH Nursing & Support Staff Benchmarks 2005 ENA Emergency Department Benchmark Survey

17. Patient Flow Project System Project Teams Cambridge Health Alliance

18. Patient Flow is a Hospital-Wide Concern • Every hospital unit has a part to play—the ED cannot solve the flow problem alone. Transport Housekeeping Case Mgmt. Food Services Radiology Hospitalist Admitting & Registration Laboratory

19. Project Charter

20. 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

21. 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

22. Focus is Across the Continuum 22

23. Fundamental Mission of Teams

24. Project Methodology

25. 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)

27. 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

28. Recommendations • Process to improve quality of care • Diagnostics: • Order sets • Pneumatic Tubes in all EDs • Labeling lab specimens with a barcode label • Receiving the specimens in the lab using a barcode wand • Throughput: • Early identification of admissions • Maximize 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

29. 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 • 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

32. 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

33. EPIC ASAP Emergency Department Information System Cambridge Health Alliance

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. Tracking Board

38. ED Manager View

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 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

43. ED Turnaround Time

44. ED Press Ganey Patient Satisfaction Overall Mean Score

45. ED Left Without Being Seen Rate (%)

46. Historical Volume Trends • Annual visit volume has averaged ~28.5k visits per year • Through 5 mos, volume is down 2% from the PY CH Registered ED Visits FY07 Projected represents the fist 5 months annualized

47. ED Visits & 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)

49. Challenges • Sustain improvements • Keep the staff engaged • Continue to improve the system • Output output output….

50. Questions Cambridge Health Alliance