EMERGENCY DEPARTMENT OPERATIONAL IMPROVEMENTS UHC January 27 2010

EMERGENCY DEPARTMENT OPERATIONAL IMPROVEMENTS UHC January 27, 2010 Assaad J. Sayah, MD, FACEP Chief, Emergency Medicine Cambridge Health Alliance

Overview of Cambridge Health Alliance: Provider Network Hospital: l 3 campuses with 24 -hour Emergency Services: – – – l Community-based Primary Care and Mental Health Services: – – l The Cambridge Hospital Somerville Hospital (7/1/96) Whidden Memorial Hospital (7/1/01) services at hospital campuses 18 neighborhood health centers, 4 school-based health centers CHAPO: Cambridge Health Alliance Physicians Organization – – Employer and contractor for MD services Physician services organization – provider enrollment, billing, claiming, malpractice coverage, HR support 2

Overview of Cambridge Health Alliance: Non Provider Components l Network Health- a statewide managed Medicaid health plan – l Medicaid products: Commonwealth Care products: 92, 785 covered lives 68, 280 covered lives Public Health: – – Includes Cambridge Public Health Department and Institute for Community Health Work closely with public health departments in Everett and Somerville l Alliance Foundation for Community Health (Philanthropy) l Academics: – Teaching affiliations with: l l l – Harvard Medical School Tufts Univ. School of Medicine Harvard School of Public Health Teaching Affiliate Training programs in social work, nursing, and occupational/physical therapy 3

Regional Safety Net Provider l Largest proportional provider of uncompensated care in the State. (33% of our service volume) AND (51% Medicaid & 28% Medicare) l Care for uninsured patients from over 257 MA communities l Many patients travel to overcome access-to-care barriers (uninsured or under-insured, culturally and linguistically appropriate care) l Leading state-wide acute hospital provider of inpatient psychiatry – – – 10% of the statewide mental health discharges 33% of statewide mental health free care discharges. greater than 33% of our patients and 57% of our mental health patients come from outside our 7 -town primary service area 4

Why Change ? l l l Change in Healthcare environment Change in Healthcare reimbursement No Growth Poor patient satisfaction Inefficiencies 5

Historical State CH Registered ED Visits • Annual visit volume has averaged ~28. 5 k visits per year • Through 5 mos, volume is down 2% from the PY FY 07 Projected represents the fist 5 months annualized 6

Essential Elements l Leadership Team – – l Constitution Alignment Commitment Communication Administration Support 7

ED Vision for the Future Current State Process • Patient Flow Project • ED Flow • Inpt. Discharges • MD & RN communication between ED and Inpt. Unit • Triage/Registration • Laboratory TAT • Transfer Leakage Staffing • MD Staffing/Productivity • Nursing • Clinical Support • Administrative • Registration Capital Investment • ED Information System • Tracking Board • Electronic Medical Record • ED Front End Redesign • Wireless Bedside Registration Future State (2 -3 yrs) • Best Practice Patient Satisfaction • Door to Doc (30 mins / 90%) • Increased volume and capacity 8

Staffing l MD Staffing / productivity – – – Culture Market analysis Comp plan Incentive Feedback 9

2007 Hourly Compensation • The goal is to close the compensation gap between CHA and competitors • Recognizing the magnitude of the salary gap, the 2007 proposal is to reduce less than half the gap between the CHA and the rest of the marketplace Fully Loaded Hourly Compensation (Includes fringe & excludes malpractice) Gap Midpoint $176. 02 10

Two Tiered Compensation Total Compensation Guaranteed Base Salary Total Compensation l l Salary Withhold Market Competitive Experience based BC / BE Reviewed annually Incorporates: – – – Salary Withhold Total Compensation Salary Withhold “Performance Bonus” – Productivity Quality Patient Satisfaction Citizenship Guaranteed Base Salary 11

Monthly Physician Summary 12

Quality & PT Satisfaction ØTimely Chart Completion ØCHA-wide Initiatives (e. g. CAP Antibiotic Time) ØChart Review for clinical compliance and appropriateness ØDocumentation of Conscious Sedation ØIncident Review ØPress Ganey by Physician ØPain Management ØPT Satisfaction (by measure of Complaints & Compliments) ØPT Flow Metrics /Throughput times ØRestraints ØHouse Staff Evaluations ØOther 13

Citizenship Ø Ø Ø Ø Ø Staff Meeting Attendance Committee Participation & Leadership Team Player (e. g. shift coverage & flexibility) Administrative Duties & Scholarly Activities Community Involvement Staff Compliments & Concerns Compliance with administrative initiatives Other non-required activities which contribute to Emergency Medicine Other 14

Staffing l l l Nursing / Other Culture Support 15

CH Nursing & Support Staff Benchmarks 2005 ENA Emergency Department Benchmark Survey 16

Patient Flow Project System Project Teams Cambridge Health Alliance

Patient Flow is a Hospital-Wide Concern l Every hospital unit has a part to play—the ED cannot solve the flow problem alone. 18

Project Charter 19

Patient Flow Project Goals l l l Improve patient flow on all 3 campuses Do so in a timely, safe, effective, efficient, and patient-centered manner Implement best practices Utilize improvement methodologies, tools, and measures Utilize a multi-disciplinary, multi-campus single solution approach Engage hospital staff 20

Structure l l l Identify common issues across the system Consolidate various campus teams working on the same topic Multiple disciplines (MD, RN, Support Staff) Coordination among the teams Avoid redundant work Develop aggressive timelines for deliverables 21

Focus is Across the Continuum 22 22

Fundamental Mission of Teams Team Mission ED Patient Flow Minimize time patients spend in the ED through the application of “best practices” Laboratory Turnaround Time Manage the ordering, collecting, testing, and verification of lab work through improved and standardized procedures No Delay Nurse Report Transport admitted patients to inpatient unit within 30 minutes of ED nurse giving report Physician Admitting Orders Expedite completion of admitting orders for admitted ED patients Inpatient Discharges Decrease length of stay through effective discharge planning activities 23

Project Methodology 24

Recommendations l Change ED flow – – – Patient partner Mini Registration Triage patients in less than or equal to national average of 7 minutes l – – – Bedside Registration Rapid assessment Maximization of bed utilization l – ESI Culture change Admissions to virtual ED beds 25

Recommendations l Redefining roles of staff – – RNs and PAR IIs draw labs Charge Nurse Role RN’s discharging patients Create MD Order Sets l – This has streamlined order entry Create RN Order Sets (MD Standing Orders) 26

Recommendations l IT: – – l System Integration: – – – l EPIC / ASAP Dictation PACS MUSE PCP Initial notification Heads up from PCP and EMS Medical record access Access to ED workup Referral Standardization of: – – P &P, Guidelines ED documents Equipment Material 27

Recommendations l l Process to improve quality of care Diagnostics: – – l Order sets Pneumatic Tubes in all EDs Labeling lab specimens with a barcode label Receiving the specimens in the lab using a barcode wand Throughput: – – – – Early identification of admissions Maximize utilization of all inpatient capacity Early assignment of inpatient beds Early handoff to the admitting service Faxing nursing report on admitted patients Early transport to the floors Escalation process l l Back up Code Help 28

ED Patient Partner l ED Patient Access Representative – – l Ambassador to patients in the waiting area Mini registration to facilitate patient flow Part of a response to deficiencies in Press Ganey patient satisfaction scores related to arrival and personal issues Press Ganey Percentile Rank 29

Rapid Assessment Overview l l l The purpose of the unit is to facilitate rapid assessment and treatment at the point of arrival in the Emergency Department Combine Express Care and Triage to form a Rapid Assessment Unit (RA) Relocate Registration inside the ED (Promotes bedside registration) Combine nursing resources from Express Care and Triage – offers the ability to care for multiple patients at once Move Physician Assistant to RA. – – The role of the PA is to rapidly assess and when applicable, treat and release the patient without entering the Acute ED. May also play a role in the initial assessment and ordering of diagnostics for acute patients. 30

ED Transfers Transfer Form Developed q Monitor External ED Transfers (100% case review by ED Site Chiefs) q Understand Reasons for Transfer q Bed Availability q Specialty Availability q Patient Preference q PCP Preference q Other q Create a feedback tool to improve services and target opportunities to reduce system leakage 31

Community Acquired Pneumonia Core Measures: In order to improve compliance with “Community Acquired Pneumonia” core measures, we developed a triage patient risk scoring process for rapid identification and management of CAP patients 32

EPIC ASAP Emergency Department Information System Cambridge Health Alliance

EPIC ASAP Implementation l The Phase 1 Implementation includes: – – – l Electronic Triage Tracking Board Electronic Discharge Documentation / Prescriptions Go Live Dates – – – TCH went live May, 2008 SH, July 2008 WH, November 2008 34

Triage & Discharge Triage l Meditech interface of arrival information, chief complaints, and other patient data l Nurses enter all triage documentation into ASAP which makes it available to the entire treatment team Discharge Documentation l Diagnosis and Disposition l Prescriptions l Discharge Instructions 35

Tracking Board l l Enables the ED to track and record all patient activities throughout their ED Visit beginning with registration through departure from the ED As the patient status changes (waiting for bed, waiting for provider, waiting for reevaluation, etc. ) color codes are assigned to alert staff Results Reporting – Lab & Radiology Orders for POC testing, urine collection, EKG request, and safety measures are flagged on the tracking board and checked off as completed 36

Tracking Board 37 37

ED Manager View 38 38

ED Dashboard 39 39

Outcomes l Results are overwhelming – – – l l l ED TAT reduced A 70% reduction in the number of patients leaving without being seen Patients have noticed a difference Press Ganey The reception area has remained empty during peak times “This was the quickest emergency room visit I've ever had” ED Staff feels like the ED is “calmer” – less chaotic 100% of patients are registered at bedside Budget neutral – – Reallocated existing staff and space Zero up front capital costs 40

ED Ambulance Diversion Total Hours on Diversion l l l Ambulance diversion is not good for our patients CHA has seen steady decreases in the number of hours on diversion Diversion has been eliminated at the Cambridge and Somerville campuses and has been significantly reduced at the Whidden 41

ED Diversion Hours / % of Time on Diversion 42

ED Turnaround Time 43

ED Press Ganey Patient Satisfaction Overall Mean Score 44

ED Left Without Being Seen Rate (%) 45

Historical Volume Trends CH Registered ED Visits • Annual visit volume has averaged ~28. 5 k visits per year • Through 5 mos, volume is down 2% from the PY FY 07 Projected represents the fist 5 months annualized 46

ED Visits & Admissions 47

Average ED Sensitive Quality Core Measures Indicator Rates l l AMI ( ASA on arrival, B Blocker on arrival) CAP (Abx within 4 hours, BC prior to Abx) 48

Challenges l l Sustain improvements Keep the staff engaged Continue to improve the system Output output…. 49

Questions Cambridge Health Alliance