Beginning in 2014, Centers for Medicare & Medicaid Services will require hospitals to report emergency department (ED) throughput times in order to receive full reimbursement. Payments will also be tied to patient satisfaction, which tends to drop sharply after two hours of waiting in the ED. When it comes to improving patient flow, the proverbial iron is glowing white-hot.
My own ED at John Muir Medical Center in Concord, CA, is a typical example. In the past, we'd worked with the inpatient floors to streamline the admissions process, but busy schedules and conflicting priorities kept getting in the way. Then last year, our administrators approached key departments about making a serious push to align goals around patient flow. This led to the development of a rapid-cycle improvement process involving the ED, the floors upstairs, staff nurses, charge nurses, nursing supervisors, housekeeping, transport and many other players. While we're still in the process of implementing improvements, it's clear that our ED admission times are improving.
Even if your administration hasn't yet approached the ED about this issue, chances are they'll be more receptive than ever to a conversation, because the shift toward value-based purchasing by CMS currently drives a great deal of their decision-making. When approaching administrators, reiterate how improving ED metrics can help the hospital maximize its revenue.
Once you've forged an alliance with your administrators, you can move ahead with formulating an action plan. The following are lessons we've learned from experience:
Take a holistic view. ED admissions are just one part of patient flow, and improvement at any step in the process benefits the whole. In our case, we found it effective to start by strengthening the inpatient discharge process and work our way backward to ED admissions.
Seek buy-in. Rather than framing patient flow as an ED-specific issue, emphasize the ways in which each collaborator — the units, the hospitalists, the ancillary staff — will benefit.
Don't rush solutions. When trying to engage others in a collaborative effort, it's important to spend time hearing and understanding everyone's perspectives first. Moving too fast into problem solving can come across as demanding and disturb the group dynamic.
Acknowledge concerns. Discussions about improvement can easily lead to venting. Leaders need to keep participants focused on the issues at hand. When concerns arise, validate these by adding them to a list of problems to address later or offering to help the person bring them to the appropriate authority. Then get the discussion back on track.
Maintain focus. When we talk about the Acute Care Continuum, it's easy to start boiling the ocean. Instead, try to tackle one small step at a time. For example, we structured our improvement plan as a series of 90-day initiatives, each narrowly focused on one realistic, measurable goal.
Above all, don't miss out on this unique opportunity. As ED physicians, we tend to hesitate before approaching administration because we're conditioned to see them as our customers. But when it comes to improving ED metrics, they want exactly what we want. We have nothing to lose by offering our expertise and partnership.