Benchmarks And Best Practices In The Emergency Department
Benchmarks and Best Practices in theEmergency DepartmentJeanne McGraynePremier Consulting Solutions1
Agenda How we use benchmarks to improve and sustainperformance Introduction to tools available Share common ED benchmarks Discuss best practices that consistently returnimproved outcomes2
Premier Consulting SolutionsImproving Clinical, Operational & Financial PerformanceDIAGNOSE Business Imperative Sponsorship Building Benchmarking/Diagnostics Interviews &Collaboration OpportunityIdentification &Quantification Initial TransformationAgendaIMPROVEMEASURE Accelerated Solutions Performance &Realization TrackingDevelopment: KPI’s Transformation ScorecardsAgenda Validation Monthly Stoplight& PrioritizationManagement Execution PlanReportingDevelopment Work Team ID Charters & WorkplanDevelopment Implementation &ExecutionCOMMUNICATE Budget Neutrality Continuous ImprovementSUSTAIN3
Trends and Issues in Emergency Care It’s all about theEconomy Patients Staff Physicians Payers Increasingregulatory pressure What does it meanfor ED Operations?4
Finding Balance in ED ces:Rooms/StaffRooms/StaffVolumeVolume5
Why Benchmark? To set goals To find peer organizations To discover better performing organizations To identify practices which result in betteroutcomes6
Key Data Sources for Benchmarking ED Performance Premier Emergency Department Benchmarking Database 90 hospitals Free (Except time required to complete the ED Survey) Excel based Operations Advisor 600 hospitals Labor and supply outcomes Clinical Advisor Physician performanceClinical performanceFinancial performanceCompliance7
Emergency Department Patient Flow ProcessesDoor to DoctorDoctor toDispositionDisposition toDischarge/AdmitInformation SystemConsultant/HospitalistArrival PatternsFunctionalityResponseEMS volumeRN/MD/IncentivesTriage Staffing and Staffing/Ratios/Skill mixCash CollectionsProcessesRN/MD Room stic TestingPracticePatient PlacementSupportIP Bed Availability“Fast Track” assignmentProtocol UseIP Nurse StaffingED Capacity Team workRooms/Staff X LOS8
Emergency Department Patient Flow DataDoor to DoctorVolumesAcuity/Admission %Arrival PatternsPayer MixLeft Without BeingSeen/DiversionEMS TATDoor to TriageTriage TimesTriage to BedED Visits per BedDoctor toDispositionBed to MD in RoomMD to Order EntryOrder Entry to ResultED Worked Hours/VisitPatients per Provider(MD/PA/NP) Staffed HourUtilization StatisticsConsultant/HospitalistResponse timesQuality Indicators9Disposition toDischarge/AdmitDischarge Order toPatient D/CAdmit Order to IPBed AssignedIP Bed Assigned toIP Bed ReadyBed Ready to Patientin IP Bed
Annual Volumes for Emergency Departments inPremier DatabaseED Annual Volumesfor Those Reporting to ED orting Facility10
Payer MixED Payer MixSelf Pay21%Commercial 22%WorkersCompensation2%HMO11%Medicare19%Medicaid, 18%11
Triage AcuityTriage Acuity - 5 Level SystemLevel 510%Triage Acuity - 3 Level SystemEmergent9%Level 16%Level 219%Level 427%NonUrgent52%Level 338%12Urgent39%
ED Admission ActivityPercent ofED Patients who are Admitted40.0%30.0%20.0%10.0%0.0%Percent of total ED visits that 17.6%14.0%18.2%32.0%Percent of Inpatient Admissions Originating in ED100%80%60%40%20%0%Percent of inpatient admissions thatcome from 0%13
ED Quality IndicatorsED Quality %AMA0.00%0.69%0.37%0.81%5.00%48 Hour Returns0.01%2.00%1.00%2.43%8.00%72 Hour Returns0.00%1.00%0.00%2.00%7.00%Left Without Being Seen Rate(LWBS)14
Door to Bed TimeDoor to BedOverallFast gedFast 32.7Minutes1535
Bed to Doctor BenchmarksBed to DoctorOverallFast gedFast Minutes1635
Bed to Doctor BenchmarksED Provider RelationshipPatients per Provider staffed rgeContractGroup38%3.002.001.00Small LocalGroup47%0.00Patients per MD/PA/NPstaffed 11.833.54Average Physician to Extender Ratio: 2.5 : 1Average time the ED Medical Director involved in Administrative activities: 36%17
Doctor to Disposition BenchmarksDoctor to DispositionOverallFast ischargedFast 11.4Minutes18160
Disposition to Depart BenchmarksDisposition to DepartOverallFast ischargedFast 1Minutes19160
Overall Length of Stay BenchmarksLength of Stay from Arrival to DepartOverallFast ischargedFast 81115.5191.5Minutes20350
Operations Advisor - Comparative labor and expenseDepartment Detail PercentilePeriod: 2008 Quarter 2 AnnualizedDept:Emergency DepartmentVolume: Emergency Department lity: 2073Date:November 14, 2008LABORWorkedFTEsTotalWorkedHrs/UnitTotal PaidHrs/UnitEXPENSEBenefit % Overtim e %LaborExp/UnitSupplyExp/UnitOtherExp/UnitTotal Exp/UnitSummary2073Peer 25thPeer 2.863.2213.69%7.27%7.93%7.07%4.43%5.46% 123.68 77.93 85.93 22.58 11.29 13.79 3.01 4.78 6.63 149.27 104.13 %7.05%4.43%5.46%3.30%4.58%3.48%5.17% 64.59 73.34 80.61 77.04 82.66 89.20 93.49 110.73 116.06 123.68 119.67 77.93 85.93 70.23 83.74 66.52 80.35 10.91 13.13 19.86 12.45 8.00 19.78 10.79 23.07 26.11 22.58 14.46 11.29 13.79 8.46 9.75 7.83 10.60 131.98 39.04 2.11 3.75 6.41 6.85 4.50 5.65 13.17 3.01 37.45 4.78 6.63 4.79 22.54 2.27 5.46 207.48 125.51 102.58 93.24 97.06 115.83 108.77 139.44 155.35 149.27 171.57 104.13 120.67 90.91 124.58 82.73 eer 25thPeer 50thRegional 25thRegional 50thNational 25thNational 50th21
Operations Advisor Skill Mix ComparativeEmergency Department64%Percentage of Paid 0.00%2%4%1% 2%11% 11%2%1%2%2%0.00%ManagerProf NonNrsgProf NrsgClinical NonLicensedGeneral Hospital22TechnicalSupportPremierClerical
C-KNER302-P2310175Clinical Advisor LOS by Admit Source Top .643.382.54ED Admit5.414.814.753.642.932.28Non ED Admit2.793.93.853.172.971.51
“Door to Doctor” Best Practices Quick Registration Brief triage assessment (but not too brief) Triage Nurse assigns room Active Use of Acuity/Status Column ED Tech escorts patient to room Beds are made available “Fast Track” criteria flexible Staff “Pull” patients when triage times excessive ED patient tracking system Aligned ED Physician Incentives24
“Doctor to Disposition” Best Practices “Free” Charge Nurse able to focus on moving patients outof ED Nurses pre-assigned to rooms Physicians pre-assigned to rooms Teamwork!! Reduced Variation (room set up, practice, protocols) Protocols so that expected care is anticipated Rapid laboratory turnaround times Appropriate amount of point of care testing Dedicated ED radiology staff and rapid 2D interpretations25
“Disposition to Discharge” Best Practices Measuring and monitoring disposition order to time ofdischarge by nurse. Discharge planning begins on admission Case Management/Social workers staffed in ED Smooth collections process Automated discharge instructions initiated by thephysician and reviewed by the RN with the patient26
Reduce Process Variability Through Accountability andCommunication Sharing data leads to self correcting performance andreduces variability.27
In-Patient Throughput ProcessesDecision to Admitto Orders WrittenOrder Written toBed AssignmentResponsibility/Authority forBed ControlBed TrackingConsultant/HospitalistHospital Capacity Availability andRooms/Staff X LOSResponseCritical Care/Telemetry UsePathways/Order SetsDiagnostic TestingSupport/AvailabilityTrust betweenCase ManagementAdmitting MD and EDPhysiciansMD Rounding PatternsSurgical SchedulingDischarge PracticesHousekeeping Support28Bed Assignmentto Time in BedReport andCommunicationShift Change PracticesTransportationRN Staffing/RatiosDischarge Unit
Disposition to Admit Best Practices Aligned Physician Incentives; Hospitalist contractBed Tracking systems/TransparencySurgical Schedule “Smoothing”Private Rooms; Telemetry/Oxymetry AvailabilityBed Control under Case Management“No refusal” PolicyBed Management Assigns Bed, Independent of NurseStaffing Housekeeping and Transport Services dedicated to BedManagement Receiving Nurse has time limit from bed assignment inwhich to call ED for Report (Pull) Fax Report; Bedside Report29
Questions?Jeanne McGraynePremier Consulting SolutionsPremier, Inc.(910) 947-6075jeanne mcgrayne@premierinc.com30
To set goals To find peer organizations To discover better performing organizations To identify practices which result in better outcomes. 7 Key Data Sources for Benchmarking ED Perform
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