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Engaging Your Emergency Department: Crossing the Clarity Chasm

Engaging Your Emergency Department: Crossing the Clarity Chasm. Jeffrey S. Bennett, MD, FHM, FAAP B-QIP Coach Chief, Div. of Hospital Pediatrics Medical Director, Inpatient Pediatrics Kentucky Children’s Hospital Presented on the Dec. 12 & 16, 2013 B-QIP Monthly Webinars Two Parts

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Engaging Your Emergency Department: Crossing the Clarity Chasm

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  1. Engaging Your Emergency Department: Crossing the Clarity Chasm Jeffrey S. Bennett, MD, FHM, FAAP B-QIP CoachChief, Div. of Hospital PediatricsMedical Director, Inpatient PediatricsKentucky Children’s Hospital Presented on the Dec. 12 & 16, 2013 B-QIP Monthly Webinars • Two Parts • Managing the transition of patients on ED-initiated therapies • Establishing a quality collaborative with the Emergency Department

  2. Lets face it: Its frustrating • ER Case: • 6mo infant with cough and wheezing for one day after 3 days of URI sx • Initially received 2 albuterol nebs; Mom felt like it helped • CXR: RUL infiltrate vs atelectasis • Dexamethasone and Rocephin • Called for admission due to oxygen sat 91% on RA; placed on oxygen and now sat is 95% • “All packaged up for you”

  3. Why? Why?! WHY?!!! • How much is emergency medicine like hospital medicine? • Time to think • Disposition vs Diagnosis • Triage protocols play the odds • To-the-minute scrutiny on LOS • Varied expectations of downstream physicians

  4. What’s the problem? The ER behaves differently than the hospital (or vice versa) in the treatment of common pediatric diseases like bronthiolitis. The differences create: • Inconsistent messages to families (confusion) • Distrust of the care system (patient and provider) • Effort to re-orient care and message in different context • Risk • Instability limiting the ability to improve overall care

  5. Putting things right • Challenge of stopping what’s been started • How difficult is it to stop the nebs initiated by the ER? • How difficult is it to stop the nebs initiated by a fellow hospitalist? • Are they different? Why? • How do you handle this? • (Caller participation!!!)

  6. The patient is now your patient • Reducing unnecessary therapies through active reassessment: • Time is among the best diagnostic tools in medicine, and trended measurement makes time very useful • Leverage “what we’ve learned since you were admitted” • Inform family about the “final diagnosis” and how its best treated • Be consistent within your unit; score, assessment, response • Measure your service performance and make it visible • Focus on moving one or perhaps two measures • Set a goal • Use PDCA to move to goal and sustain

  7. What B-QIP teams have said about the ED • Some of our more troublesome data is for things that have happened before hitting our floor and therefore less control for us. • ED faculty were very receptive to management guidelines, including limiting use of chest radiography • We had a new pediatric ED physician start in the last month and he seems eager to work with us on our efforts. A B-QIP site leader presented to the ED faculty at this site on Dec. 10 • We had a goal to present bronchiolitis management pathway to the ED and begin education process

  8. Collaboration with the ER • The root word of Collaborate is “labor” • Shared labor based on shared goals, shared gain • What’s in it for them? • Shorten ER LOS? • Improve admission process and reduce ED boarding? • Patient satisfaction? Cost? Hospital measures of ER performance? • What happens to the patient after admission? • How many stopped abx? Albuterol? • Measure and report back!

  9. Benchmark ER performance • Cincinnati Children’s Hospital • Ironically, many of the papers showing the lack of efficacy of treatments and CXR are done in ER settings! • Internal benchmarks: • Hospital measures of ER performance • Relative performance over time

  10. Name one time in your life your life you eagerly accepted someone else’s attempt to change you

  11. A Vehicle for Change • B-QIP is intentionally designed as a vehicle for change • Structure: Organization, tools, evidence for change • Engine: Data warehouse, analytics, deadlines • Support: Coaches, webinars, experience • You supply: • Fuel: Effort you supply, measurements you capture • Direction: Target for change in your organization • Focus: Commitment to seeing it through • Measurement is the key

  12. Principles: Change for the better • Does your hospital’s mission statement promise freaking awesome care? Mine does! • Are you there yet? We aren’t!! • Will we get there? Perhaps, if we: • Long-term aims vs. reactive change • Build a culture of stopping to fix problems • Standardize as a basis for ongoing improvement and employee empowerment • Use reliable, thoroughly tested processes and technology (evidence!!) • Develop exceptional people who embody a culture of improvement • Respect all partners, suppliers, and customers by challenging them and helping them improve Adapted from The Toyota Way Field Book by Jeffrey Liker and David Meier

  13. Where’s your opportunity? • Start talking about the problems the ER is facing • Integrate hospitalist support for ER initiatives • Find opportunities to center on “best interest of patient” • Describe the entire service from door to floor • As the patient/family see it • As the costs mount

  14. PATIENT 1 st COMMUNICATON TEAM

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