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Internal Medicine Executive Committee
Improving Emergency Department Patient SatisfactionIHS 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)
Emergency Department Overall Press Ganey ScoresFiscal Year 2007
SL-SC Comparison to other IHS Affiliates
82.6
83.7 83.8
84.5
85.2
86.8
87.7
80
81
82
83
84
85
86
87
88
89
SL-SC
Emergency Department Overall Press Ganey ScoresFiscal Year 2009
SL-SC Comparison to other IHS Affiliates
82.7
84.7 84.885.3
86.4
87.8 88.0
80
81
82
83
84
85
86
87
88
89
SL-SC
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 changeDevelop 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 developedFront line staff chosen and mentored to lead
teamsED physicians champion each teamAll ED staff involved in a committee
We know that: Front line staff “Know how to do it Best”
Shared Leadership ImplementationOur First Steps:
Our Professional Practice Model
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
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” implementationAlert 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 equipmentFinding alternative sources of funding is key
Communicate,
Communicate,
Communicate…
Never under estimate the value of communication
Data Drives Change
Transparency of DataShow 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
Emergency Department
FYTD HoursUOS (2009)
50th Percentile
2.51 2.80
January 201071% of patients seen by physician < 30 minutes93% of patients seen by physician < 60 minutes
Median Length of Stay in ED103 minutes
15% increase in visits over past 2 years
Return on Investment
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.
All Emergency Department Visits
0
10000
20000
30000
40000
50000
60000
70000
Mercy 28744 30276 30874 30704 6841
SLRMC 21657 23413 25933 27639 6634
Total 50401 53689 56807 58343 13475
Market Share 43% 44% 46% 47% 49%
2006 2007 2008 2009 YTD March 2010
Emergency Department Overall Press Ganey ScoresFiscal Year 2009
SL-SC Comparison to other IHS Affiliates
82.7
84.7 84.885.3
86.4
87.8 88.0
80
81
82
83
84
85
86
87
88
89
SL-SC
Emergency Department Overall Press Ganey ScoresFiscal Year 2007
SL-SC Comparison to other IHS Affiliates
82.6
83.7 83.8
84.5
85.2
86.8
87.7
80
81
82
83
84
85
86
87
88
89
SL-SC
It is all about the ER team
Focus on the “Patient” not on ourselves
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