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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
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Internal Medicine Executive Committee Improving Emergency Department PatientSatisfaction 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 ReimbursementWhat 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 ReimbursementWhat 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 • 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)
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” Shared Leadership ImplementationOur First Steps:
Shared Leadership ImplementationOur 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
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
“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 Patient Flow
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, Communicate… Never under estimate the value of communication
Data Drives Change • Transparency of 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 dataKeep 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
Return on Investment • January 2010 • 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.
