Using Project Management and All That Jazz to Change the Culture in the Emergency Department

1. Using Project Management and �All That Jazz� to Change the Culture in the Emergency Department Michelle Franklin, RN, BSN, MBA, CRNI, CPHQ NAHQ Kansas City, MO Saturday, October 2, 2010

2. Who Is HCA?

3. HCA owns and operates approximately 163 hospitals and approximately 105 freestanding surgery centers in 20 states and London, England HCA is the nation�s leading provider of healthcare services HCA has 180 emergency departments (including freestanding ED�s)

4. Concepts of Project Management Definition: Planning, monitoring and control of all aspects of a project and the motivation of all those involved in it to achieve the project objectives on time and to the specified cost, quality and performance

5. Project Management ResourcesPeople, equipment, material TimeTask durations, dependencies, critical path MoneyCosts, contingencies, profit ScopeProject size, goals, requirements

6. 6 Emergency Departments �We don�t fix an ED we manage an ED�.� Implications�. ED drives our volume growth (average 54% of inpatients begin in ED) Face to our community and our key service lines Significantly impacts our patient and physician satisfaction Vigilance of fundamental processes Ongoing metric and performance assessment

7. 7 ED Playbook Playbook�is a series of defined tactics with clear instructions to optimize execution with resultant improvement in outcomes and metrics Tactics are consistent with national improvement organizations e.g. IHI; NQF; Advisory Board Tactics are designed for the best and worst performers Tactics have proven effective in decreasing LOS and increasing volume in HCA pilot facilities

8. 8 Objectives of ED Playbook Grow Volume Provide Quality Care Reduce Clinical Variation Improve Targeted Metrics that drive Volume, Quality and Risk Reduction

14. 14 ED Toolkit ApproachTactics Facilitate Patient Flow

15. 15 Organization of the Playbook Divided into two sections Phase 1-Must Do Phase 2-Conditional Supportive of other Projects Bed management ESP ED Holding Unscheduled OB eMAR Each Tactic in both Phases are Tied to Targeted Metrics

16. 16 Key Points � Financial Opportunity 55% of all admits come through the ED Stable source of volume in times of economic challenge ED Operational challenges will drive away volume � both EMS and other ER patients. Alternatively, improving ED operations will grow ED volumes. Pilot market post 9.2% ED admission growth post implementation The ED must operate efficiently to grow key product lines 75% of admits for cardiac 90% of admits for neurology 61% of admits for surgery Patients with good experiences in the ED will often choose your Hospital for subsequent scheduled events.

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21. 21 Key to Improving the Metrics Implement ED playbook Role of Management Engineer Role of Dashboard and Daily Report Leverage supporting strategies (Bed Mgt, ESP, ED Holding, Unscheduled OB & eMAR) Strategies for Vigilance Monthly MOR Daily Reports Administrative Stat Tracker QCOR integration

22. Staffing Evaluations � Get Ready 22

23. 23 ED Staffing Evaluation:Schedules should meet peak and low volumes Combat the busier times with a shift in staff schedules Don�t let the early arrivals pile up to where no one feels caught up again until 4pm Think outside the box 8 and 10 hour shifts Different schedules for busy days

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26. 26 Accuracy of Triage Acuity

27. 27 Accuracy of Triage Acuity - Goal Goal is to �grade� all Nurses and monitor Acuity  Accuracy as a part of performance Advance Low Acuity Strategies

28. 28 Waiting Room Reassessments

29. 29 Waiting Room Reassessments - Goal Grade triage nurses on timely waiting room reassessments  Monitor and document reassessments for patients waiting for more than 60 minutes Audit process and documentation Triage tracker developed in EDM to trigger triage nurses

30. 30 Emergent Triage Protocols

31. 31 Emergent Evidence Based Order Sets - Goal Start Patient Treatment as soon as possible First 4 Emergent Order-Sets reviewed by all ED Directors and Medical Directors Shortness of Breath Chest Pain Peds Asthma Peds Fever ED Physician Groups agreed on Emergent set & implemented

32. 32 Triage Order Sets � Future Direction Everyone in the division should use the same protocols Best Medicine practice should be the same from Sarasota to Orlando to Hudson Order Sets should include all requirements to ensure core measure and P4P-PQRI compliance. Order Sets reviewed by CSG-Core Measure-QRS to ensure standards met Implement ePOM across division by end of 2009 Implement paper order-sets first to get staff used to the process

33. 33 Timely Registration

34. 34 Timely Registration � Goals & Tools Patient Registration completed within 60 minutes after Triage Increase communication lines between the ED Directors and PADs Registration Metrics sent out monthly to Admin teams, ED Directors, PADs, and RPADs Triage to Registration Time % LPR Allowed the numbers to tell a story

35. 35 Timely Registration � Goals & Tools

36. 36 Benefits in working together� Work through the tactics together The Directors supported each other and identified solutions together The Directors have a much better relationship than before we started The Medical Directors embraced the opportunity to work together Playbook stood as a �How To� guide for an ED Director Blake Medical Center on Autopilot

37. 37 WFD Emergency Operations 2008

38. 2009 ED Playbook Highlights Accuracy of Triage Improvements in triage accuracy seen in most facilities. Many facilities are at or better than target. Assessment Prior to MSE Noted improvements in timeliness and quality of assessments Arrival to Greet reduction has mitigated the need for reassessments Option 1 � use this single summary slide plus the graphs. Is this statement accurate? Kristen summarized comments from 3 groups into an enterprise result.Option 1 � use this single summary slide plus the graphs. Is this statement accurate? Kristen summarized comments from 3 groups into an enterprise result.

39. 2009 ED Playbook Highlights Timely Registration As we further reduce LOS these metrics will need constant monitoring and attention Emergent Order Sets Remains unfinished Goal is standardization across HCA Must include in CPOE development Option 1 � use this single summary slide plus the graphs. Is this statement accurate? Kristen summarized comments from 3 groups into an enterprise result.Option 1 � use this single summary slide plus the graphs. Is this statement accurate? Kristen summarized comments from 3 groups into an enterprise result.

40. The Big DOT !!

45. Ongoing ActivitiesForever and ever and ever and ever���. Annual Staffing analysis of all key stakeholders Minimum of annual prior to budge More frequently as new strategies are implemented Monthly review of Registration Performance Can be done formally/informally Both ED Director and PAS Director should review and discuss progress or regression

46. Ongoing ActivitiesForever and ever and ever and ever���. Need a Plan�. Accuracy of Triage Reassessment Prior to MSE Accuracy of Triage All or Some Old or New Trends Spot Checks Include Staff in the Process

47. Ongoing ActivitiesForever and ever and ever and ever���. Reassessment Prior to MSE Arrival to Greet Times Mitigate What is the plan with surge? How do staff pull the triggers for help to meet this standard? How do we catch the infrequent??

48. What We Inspect We Expect!! How do we keep focus without undo burden How do we fully engage staff into owning the process changes How do we build this into our ongoing monitoring How do we see our operations through another �lens�

49. Lessons Learned We still want to check off the box�. When the cat is away�� Necessity is the mother of invention�. Many hands make light work�. Move the �big dot� and the others will follow�

50. Phase 2

51. Emergent Evidence Based Order Sets Goals: ONE emergent order set will exist for each division They will be built into CPOE as that is rolled out CPOE saturation % will not include Emergent Protocol orders.

52. Playbook (2) Metricsaka �The Big Dot�

53. Traffic Control What is it? Effective and efficient traffic control in the Emergency Department involves an orchestrated combination of visual, written and oral communication modes. Visual�Electronic trackers�where is your patient, and what is the status of their visit ? Written�Chart racks�where is the clipboard and how do we know orders have been written? Oral�Telephones/Radios�how do we deliver verbal communication effectively and efficiently?

54. Traffic Control Why is it important? Traffic control in the Emergency Department is essential to successful and timely throughput of patients. Traffic control is crucial in providing Emergency Departments with streamlined and efficient workflow capabilities, including organizing key patient data, making it accessible to all who need it. Traffic control reduces potential for error and lost data and improves communication between caregivers to allow continuity of care.

55. Expedited Intake What is it? Any Open Bed/Immediate Bedding: The process of bringing a patient to an available treatment space once pre-registration in ADM or recept in EDM is complete, WITHOUT stopping in the triage area. Any Open Bed requires three elements: 1) available bed/treatment space; 2) available staff to care for the patient; 3) consideration of the acuity of other patients assigned to the care-giver. The goal of the process is to improve patient flow at the front end of the patient visit in order to decrease the time the patient waits to see the provider. Triage assessment and complete registration can be done at the bedside. Rapid Triage: A brief assessment performed by an RN, to quickly evaluate the patient�s general appearance for problems that require immediate attention. At a minimum a rapid triage assessment includes obtaining subjective and objective assessments including airway, breathing, circulation and disability or neurologic status (ABCD). Acuity category is assigned at this time. Rapid triage helps to quickly sort patients and determine which patients are most acute and need to be seen first. Team Triage/EMS Offload: Team Triage for EMS offloading is the process of having a designated team of ED personnel quickly offload and triage a patient brought in by ambulance. This tactic also includes assigning a bed for EMS crew upon receipt of a radio report, communicating the bet assignment to EMS for immediate bedding upon arrival,

56. Expedited Intake Why is it important? Minimizing �non-value-add� time at the front end of the patient encounter increases patient satisfaction and decreases LPT and LPMSE. Streamlining front end processes decreases duplication of work such as duplicating data collection at Triage and during the nursing assessment. An overly comprehensive approach to triage can increase patient wait times, especially during peak hours, unnecessarily Decreasing arrival to triage and arrival to bed times can significantly reduce the amount of time the patient waits to see the provider (arrival to greet time).

57. Low Acuity Strategy What is it? A low acuity patient throughput strategy is a method to quickly and efficiently process low acuity patients through the ED 24/7. It may be an ESP or RME process, or it may be a method of truly �fast-tracking� low acuity patients through the ED. Why is this important? Roughly 40% of all patients presenting to the ED are non-urgent The rate of patients leaving prior to triage or prior to MSE is higher than the rest of the ED population Consistent process for throughput of patients requiring non-urgent care is shown to decrease ED LOS

58. Low Acuity Strategy Identification of Strategy due 11/5/10 to include: Consistent Low Acuity documentation process Consistent process for Low Acuity Throughput 24/7 Type of strategy deployed (ESP, Fast Track, etc) Attestation of strategy deployment due 12/3/10. Should see metric (LOS, LPT) improvement

59. Metrics CSG Emergency ServicesED Playbook 2009 Final Milestone Report

66. Patient Satisfaction vs. Average LOS-Admitted & Discharged

67. Capital Division

68. Central & West Texas Division

69. Continental Division

70. Delta Division

71. East Florida Division

72. Far West Division

73. Gulf Coast Division

74. Midwest Division

75. Mountain Division

76. North Florida Division

77. North Texas Division

78. San Antonio Division

79. South Atlantic Division

80. Tristar Division

81. West Florida Division