No one plans to spend Saturday afternoon in the ED. This reality hit home when our laughter from lunch with old friends was pierced by the sound of glass shattering. We heard a scream and realized my daughter had just run through a sliding plate-glass door. During this experience, I had a rare opportunity to observe my profession from the patient/family side of things.
What struck me most is the tightrope that ED providers must walk while providing high-quality, patient-centered care. As a parent, I valued the time the doctors and nurses spent with my child and me. On the other hand, I understood the pressures they were under to move us as quickly as possible through the diagnostic and treatment process. They worked hard to provide a healthy dose of empathy without sacrificing efficiency.
ED physicians' ability to manage these opposing forces will become even more crucial over the next year or so as Centers for Medicare & Medicaid Services (CMS) rolls out its latest patient satisfaction survey — okay, patient opinion survey — the Emergency Department Consumer Assessment of Healthcare Providers and Systems (ED-CAHPS).
ED-CAHPS is the latest iteration of the National Quality Strategy outlined in the Affordable Care Act. It's part of an ongoing rollout of quality surveys administered by the U.S. Agency for Healthcare Research and Quality (AHRQ). According to CMS:
Stakeholder organizations have received preliminary drafts of the survey, and beta testing is in progress to gather baseline data. While specific questions haven't been publicized, it's a safe bet that ED-CAHPS will follow HCAHPS lead, with an emphasis on respectful communication with both patients and their families. CMS hasn't announced a firm implementation date, but indications point toward late 2014 or early 2015.
So what does this mean for hospitals? In the future, ED-CAPS will likely be tied to Medicare reimbursement. Although CMS hasn't yet announced a definitive formula for this, its safe to assume it could have significant impact on hospitals' bottom lines. In addition, a survey of hospital administrators revealed that many believe CAHPS performance will eventually be tied to value-based purchasing.
Although ED-CAHPS is still months away, it's important to focus on improving patient experience in the ED now. Here are a few thoughts on where to focus your improvement efforts:
Emphasize efficiency. Research strongly suggests that overall patient satisfaction is inversely proportional to ED wait times. An analysis by Press Ganey found that a wait of six or more hours correlated with a 13 percent drop in satisfaction scores.
Focus on your front and back doors. Patient experiences during arrival, triage and registration set the tone for a stay. But backdoor processes (those that move admitted patients to the units) also have significant impact on throughput. Each patient who goes upstairs opens a bed for one in the waiting room. Additionally, transitioning these patients to a more comfortable, less chaotic environment sooner leads to a better patient experience (which we recognize is being measured by HCAHPS).
Enlist your hospital's help. While front-end processes are under direct control of the ED, improving back-end processes requires cooperation with the admitting team. A good approach for building buy-in: explain how streamlining the admissions process will improve patient flow not only in the ED, but also across the entire hospital.
Start by refining admissions processes. Be explicit as possible here. Break the process into a series of discreet steps, with parallel tracks for physicians and nursing. Set measurable expectations, i.e., noncritical patients will be admitted within X hours.
Facilitate physician orders. Most hospitals can't admit patients without orders from the admitting physician, so this is a common sticking point. Make it easier for the inpatient team to provide brief orders on non-critical patients, allowing faster bed assignments and improved throughput. Many sites utilize limited transition or bridging orders to achieve this goal. Systems like computerized physician order entry (CPOE) and remote order entry can also help speed the process.
Communicate bed availability. In an ideal world, nurses inform the ED the moment an inpatient bed is available (or respond when the ED calls to inquire). But patient crises, shift changes and busy schedules can delay this crucial exchange. To get around this, some hospitals have implemented visual communication systems that allow ED nurses to see bed openings in real-time. This eliminates the need for phone calls and in-person inquiries.
Time communications appropriately. Ideally, an inpatient bed should be empty, cleaned, staffed with nurses and ready to be occupied before the ED is informed it's available.
Dedicate staffing to the admissions process. Some hospitals use an "admissions nurse" to bridge the gap between ED and inpatient care. This person facilitates communication between departments, completes paperwork and assists the patient through the transition. This can decrease the burden on the ED nurse so he can focus on the next ED patient, again facilitating throughput.
Create pull. When the ED is constantly in a position where it's "pushing" admitted patients toward the inpatient floors, patient flow suffers across the hospital and satisfaction scores follow suit. A proactive approach by the admitting team helps to keep things moving along while easing the burdens on ED staff and patients.
Take things one patient at a time. While throughput is key, some patients and their families really do need our empathy and attention. Physicians should feel free to slow things down and explain the processes at work when that's what it takes to meet a patient's needs. A few minutes of meaningful interaction with a caring provider can make all the difference. It certainly did for me during my child's visit.