Start the Clock!
The MBQIP quality measures discussed in the next section are time sensitive. To provide the highest standard of quality care for your patients, the care staff must formulate processes that allow for timely and appropriate responses to patient’s needs. Evaluating your ED practices before making changes is helpful and can prove to be less disruptive to staff. The Studer Group
www.studergroup.com has created a document to help you diagnose areas for improvement. Multiple resources and tools are available in the appendices of this document and on the Stratis Health website
The document below is divided into three distinct segments relevant to the phases of ED throughput. The questions listed for process evaluation in each area can help you and your ED Performance Improvement team focus on the key areas where improvement is needed. When initiating improvement, it is often useful to divide areas into: people, processes, environment and equipment. The team can examine how each of these areas impact the improvement effort as well as divide opportunities or best practices into these 3 areas. This focus may help you diagnose issues related to time-sensitive patient care.
Taking Your ED to Next Level-Understanding Flow Issues
The next time-sensitive measures will have their focus in the ED. To perform well on these measures, it is essential to examine the processes impacting your ED. Remember, when evaluating areas of opportunity, it is always helpful to examine areas impacting your ED: types of patients received, ambulance service contracts, ED physician/provider contracts, admission offices, and inpatient units. Broken or dysfunctional processes in any of these areas can impact your ED services. You will see in the table below that by dividing up your ED throughput into 3 categories or distinct functions, you can develop insight into flow issues.
OP- 18, 20, and 22
ED throughput can be a complex and complicated process to improve. Detecting the time from arrival to departure can have an indirect impact on the number of patients leaving without being seen and patient satisfaction scores in the ED population. Evaluating metrics in this measure may help you to determine staffing levels and/or needs for throughput improvement. Below are some examples of best practices.
These measures are best managed when concurrent review (closest to the point of delivery) is used. The best way to build in concurrent review in these processes is to use checklists, prompts in the EHR, and/or teamwork. Having these redundant barriers in place can help prevent an error or omission in care from reaching the patient.
OP-18 MEDIAN TIME FROM ED ARRIVAL TO ED DEPARTURE FOR DISCHARGED PATIENTS
OP-20 DOOR TO DIAGNOSTIC EVALUATION BY QUALIFIED MEDICAL PROFESSIONAL
OP-22 PATIENTS LEFT WITHOUT BEING SEEN
Overall Best Practice Tactics
• Synchronize all clocks and equipment in the ED
• Develop a process for plant operations and/or ED leadership for ongoing “clock checks”
• Work with a team to track a patient from arrival to discharge. Track incremental time and look for delays and bottlenecks in processes.
• Consider Open Bed Policy-allowing patients to advance to open bed upon after initial triage screening (AHRQ Improving Patient Flow and Reducing Department Overcrowding)
• Have low acuity patients evaluated by provider upon arrival and discharged as soon as full registration is completed
• Consider RN triage and preliminary registration
• Provider/RN team evaluations or “provider in triage” to assess patients immediately upon arrival
• Bedside registration can be especially effective for EDs with low-acuity patients
• Build prompts in the EHR or paper forms to track timeframes.
• Partner with your registration staff and IT departments on data collection. Many software packages that capture patient entry into the ED also have mechanisms to capture several of these data points. At the end of the week or month, reports can be run to establish the data points.
• Share data on time before physician evaluation and total time in ED
• Set realistic goals to reduce times
OP-22 PATIENTS LEFT WITHOUT BEING SEEN (LWBS)
Detecting the number of patients who are leaving your ED without being seen can be beneficial on several levels. Primarily, it can be harmful not only to patients returning to the community or home without receiving care, but also to the health of the patient’s family and significant others. Secondly, knowing the number and types of patients (diagnoses, age) who are leaving the ED without being seen can provide information needed to drive the QI process.
Best Practice Tactics
• Establish and implement staff education about improving patient experiences, e.g., frequent updates on wait time (see Resource Section below for a variety of tactics)
• Use trained volunteers/staff in the ED to provide updates to patients
• Use nurse or mid-level practitioner in the ED triage
• Provide electronic boards with wait times
• Improved time-tracking in the EHR, e.g., seen by provider time
• Develop detailed tracking of arrival time
• Reduce door to evaluation time
• Use nurse or mid-level practitioner in ED triage
• Capture and visit with patients before they leave without being seen
• Conduct regular patient analyses for trends
• Utilize the knowledge that literature supports the key reason for LWBS is wait times and that communication about wait times is a key driver to prevent LWBS
• AHRQ Patient Flow Guide
• Work with registration, IT or data vendor as data may be easily collected from electronic or manual registration logs
• Conduct regular patient record analyses to identify and understand trends, such as a diagnosis-related delays
• The best practices to reduce door to evaluation by qualified medical provider (OP-20) are likely to reduce the number of patients who leave without being seen