An ED Shares Its Secrets for Rapid Operational Improvements

Michael Mesisca

Michael Mesisca , DO

ED Medical Director, Moreno Valley Medical Center
Gillian Dargan

Gillian Dargan , RN, MSN

Practice Management Consultant

Published November 06, 2018

Children sharing a secret

Undertaking major emergency department (ED) quality initiatives requires not only transforming processes, but also a dedicated team of physicians and nurses and involved leadership. Can change only be achieved with a long-term effort? Not necessarily — if you a have strong culture.

The power of culture is evident at Kaiser Permanente Moreno Valley Medical Center in Southern California. In today’s post, we’ll look at how our ED achieved dramatic clinical and operational improvements in just a few months.

Moreno Valley Medical Center had many struggles leading up to its purchase eight years ago by Kaiser Permanente (KP). Since that time, the entire hospital had seen tremendous quality improvement.

The ED, however, while under the care of a contracted physician group, remained a challenge. In particular, the site had struggled to recruit emergency medicine physicians (there's quite a bit of competition for hiring in our area) and was in need of significant patient experience, quality, and operational improvements.

Seeking an innovative partner to help them accomplish their goals, the hospital leaders turned to Vituity to staff its ED in 2015. Because Vituity had a strong presence at other hospitals in the community, Kaiser felt the partnership would boost its ability to recruit skilled, board-certified emergency medicine physicians in the area.

Planning for Success

We are fortunate that local KP leadership and Vituity share many similar values regarding provision of patient-centered care, achieving operational excellence, and investing in physician and nursing leadership development. So it was a perfect match.

Three months before the Vituity contract went live, we rolled up our sleeves and began planning for success. This started with meetings among the hospital leadership, the incoming ED Medical Director and Lead Advanced Provider, and Vituity regional leaders.

To help promote success, we also brought in Vituity practice management consultants. These organizational experts are skilled change managers who work with the entire ED team to implement best practices.

With the help of our consultants, we conducted an intensive two-day visit with hospital, ED, and ancillary services leaders at Moreno Valley to develop a comprehensive site assessment. Once we understood the hospital’s challenges, needs, and goals, we held weekly operational team meetings in the months leading up to the contract “go live.”

Vituity physicians and KP nurses worked together and were a critical part of the planning process. The nurses were eager and enthusiastic to help reach our goals. Because many of them had previously worked at other Vituity EDs in the community, they understood our culture and the signature processes we wanted to implement.

Our first order of business was to address the ED’s long wait times. Before Vituity came on board, time to provider was over an hour. Leadership, nurses, providers, and ancillary staff all agreed this was the ED’s most pressing problem, so we built a culture around solving it.

Tackling Improvement as a Team

Day one of the contract arrived, and the team was ready to make process improvement history! During this time, the ED had only 12 beds and was in the midst of a major construction project to add 16 more plus a four-bed fast-track program. So improving throughput to maximize every inch of space in the ED was vital.

With input from the nursing staff, physicians, and ancillary services, we launched Rapid Medical Evaluation® (RME) to address our long wait times and throughput challenges. This signature Vituity process puts a physician in triage with a nurse to perform team intakes. Within just one month, time to provider dropped from 67 minutes to 12, reducing length of stay for our patients by nearly an hour.

The successful implementation of RME marked the beginning of a culture shift at Moreno Valley. By working as a team, everyone saw what we could accomplish in a very short time frame, for ourselves and our patients. Further, the positive workplace we’d created mitigated the morale and staffing issues that had previously plagued the ED.

Because of the trust and confidence we’d built in each other, subsequent operational and quality improvement initiatives became that much easier.

Riding the Improvement Wave

With RME in place, the team immediately moved on to its next project: establishing multidisciplinary rounds. Prior to multidisciplinary rounds, we’d been coordinating patient care with individuals by calling the case manager, then the social worker, and finally the hospitalist. It was inefficient and increased the chances of miscommunication.

Each morning at 8:30 a.m. we now gather everyone involved in a patient’s care in the ED, including the emergency physician, charge nurse, hospitalist, case manager, and social worker. Together we round on patients who are boarding in the ED while awaiting mental health, social services, or nursing home placement, as well as any patient with a complicated disposition. The entire team collaborates on how to provide the best, most appropriate care. This initiative has led to quicker dispositions and improved patient care. It has also drawn the attention of several other Vituity sites that are implementing multidisciplinary rounds to achieve similar results.

We’ve also instituted a surge plan to decompress the ED during times of high patient census, which has helped us maintain our operational improvements in throughput and patient experience.

Finally, our team has implemented a protocol to better manage patients presenting with chronic pain. To decrease opioid use, we look for compassionate, non-narcotic ways to manage pain, and we educate patients about the drawbacks of long-term opioid use for chronic pain control. Our philosophy is that the primary care physician is the best person to manage chronic pain, and we do not routinely refill narcotic prescriptions in the ED.

The consistency among the team in our efforts has resulted in a 25 percent decrease in opioid utilization in the ED and a huge improvement in our work environment and the quality of care we are delivering.

Analyzing Next Steps: Patient Experience

Our newly expanded, 32-bed ED has been up and running for over a year now. With several rapid quality improvement efforts under our belts, our next focus is on enhancing the patient experience.

We prefer to avoid the term “patient satisfaction,” because we can’t control whether or not patients are satisfied. But we can control the experience and how well we treat people, and we aim to treat every patient like a member of our own family. Everything we do centers on this goal.

To that end, our providers now hand out business cards in triage. We also use care cards to help patients understand their plan of care. We’ve recently implemented callbacks to discharged patients, which have yielded valuable feedback, service recovery opportunities, and improved patient experience.

Reducing wait times after triage will also be a focus for our team in the coming months. With the collaborative Vituity and KP patient-centered culture of continuous improvement and recent string of successes, I’m confident we’ll get there.

To learn more about the role of culture in quality improvement, check out this post by Vituity CEO Imamu Tomlinson, MD.

Originally published August 21, 2017. Updated Feb. 20, 2018.

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