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Focus on the goal: Be most efficient

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   By Tracy Doughty, September 2011

How an EDIS can be used to support change.

In a world where emergency departments (EDs) must rise to meet the challenges of overcrowding, longer patient wait times, regulatory changes and economic demands, hospitals must find a way to keep focused on the needs and satisfaction of their patients, clinicians and hospital administration.

Huntsville Hospital has found a way: Focus on a common goal.

Provide the best possible care in the most efficient manner

Decisions made in Huntsville Hospital's emergency departments are driven by the goal of quality patient care. Being more efficient means doing things faster without sacrificing patient satisfaction.

As an 881-bed, not-for-profit institution, Huntsville Hospital is the second largest hospital in Alabama, with more than 6,500 employees and a medical staff with more than 700 physicians. Huntsville Hospital serves as the major referral hospital and trauma center for patients throughout the Tennessee Valley. The hospital also operates Huntsville Hospital for Women & Children, one of only three pediatric hospitals in Alabama.

A common goal unites the team. Objectives help guide day-to-day operations and provide a framework for decision-making; key performance indicators provide a means to measure and manage success.

More than 150,000 patients are treated each year in Huntsville Hospital's three EDs: an 85-bed adult ED, a 16-bed pediatric ED and a nine-bed urgent care in Madison, Ala., which will become an ED when the Madison Hospital opens in 2012. On a daily basis, care is given to more than 400 patients each day, and over 25 percent of all hospital admissions come through one of Huntsville Hospital's EDs.

Such a busy ED requires attention to the processes that are in place with the goal of continual process improvement, in order to continue to provide the quality of patient care Huntsville Hospital is known for. Huntsville Hospital is able to seamlessly incorporate changes, whether a state or federal mandate, a hospital-wide process improvement or a revision of an existing ED process.

ED SCORE CARD EXAMPLE

 

 

Last 3 months

Last month

Current month

Budgeted patient visits

 

 

 

 

Actual patient
visits

 

 

 

 

Actual patient visits (last year)

 

 

 

 

 

GOAL

 

 

 

Left without treatment

%

 

 

 

# of ED
discharges

 

 

 

 

Average length of stay

X minutes

 

 

 

# of ED
admissions

 

 

 

 

Average admission time

X minutes

 

 

 

 

 

 

 

 

Turnaround
times

 

 

 

 

Registration

X minutes

 

 

 

LAB (order to completion)

X minutes

 

 

 

Radiology  (order to completion)

X minutes

 

 

 

 

 

 

 

 

Process times

 

 

 

 

Arrival - Triage

X minutes

 

 

 

Triage - Placed on bed

X minutes

 

 

 

Seen by M.D.

X minutes

 

 

 

Disposition

X minutes

 

 

 

Left ED

X minutes

 

 

 

 

 

 

 

 

Patient satisfacton

%

 

 

 

Where to start: The right foundation

An emergency department information system (EDIS) can have a dramatic effect on patient wait times, length of stay and elopements and can also provide a solid foundation on which to build and refine process improvements to achieve efficiency goals.

In 2006, a multi-disciplinary team identified, evaluated and selected an EDIS that would become the foundation for improving ED efficiency. Wellsoft EDIS was the choice. Huntsville Hospital would have a standards-based platform that would allow them to easily incorporate new or refine existing processes, whether clinical or administrative.

Initially used to automate triage and patient tracking, the benefits of automating more processes by using Wellsoft EDIS became apparent. Wellsoft clinical documentation was added in 2008 for quick, legible and complete documentation of patient care. Electronic order entry, or CPOE, was added in 2010. Using HL7 interfaces, laboratory, radiology and cardiology orders were sent electronically from Wellsoft EDIS to ancillary hospital systems and real-time results are tracked automatically.

Implementing changes to become more efficient has had a positive effect on patient wait times, length of stay and elopements.

Know the score; track data to find areas of improvement

Tracking a few key metrics helps clinicians and hospital leaders monitor results and more easily identify areas for improvement.

Wellsoft EDIS automatically captures, time-stamps and tracks patient wait and activity times at each step of the emergency department visit. Patients are tracked from pre-admission through final disposition and time-stamps correlate to each patient's overall length of stay (LOS) in the ED. Bottlenecks are easily identified. With data collected on patient flow, action plans are being developed to improve throughput time, which, in turn, will increase patient satisfaction.

The team at Huntsville Hospital has created a monthly dashboard that includes key data generated during and after each ED patient visit. This dashboard is shared with senior leadership to track the impact of process changes and improvements throughout the hospital.

Drilling down on any monthly metric variance to understand what was occurring on a specific day of the week, at a specific time, helps to identify potential process improvements. If the door-to-triage times are within range, except between noon and 3 p.m. each afternoon, this might prompt the need for a greeter. This process change could be easily implemented and then observed to determine if the change works.

For Huntsville Hospital, having an EDIS that essentially writes its monthly ED scorecard reports automatically is invaluable. Without an EDIS, there is no easy way to collect data and measure patient throughput. To provide metrics on a monthly basis would require manually reviewing hundreds of paper charts. The data would be subjective, and you would hope you have the right information and are reaching the right conclusions. It would be like driving a bus blindfolded. You might someday reach your destination, but getting there would be difficult. 

Change is good

The team at Huntsville Hospital welcomes and embraces change, which helps them realize their objective of improving efficiency.

Reflecting staff members' input helps optimize workflow. For example, when ED physicians suggested a new way to help improve patient communication, the idea was quickly made a reality. The appeal was for a way to document and track patient requests, such as "patient is hungry," "patient wants to see doctor" and "patient's family has questions" right on the ED patient track.

With a few simple changes, a new tracking column was added to the patient track. As requests are made, they are entered into a "patient request" column and color coded to identify what is requested, who should handle the request (doctor, nurse) and if the request has been fulfilled. 

This simple change means ED staff no longer has to write down patient requests and hope they remember to take care of them. Doctors and nurses are more organized, and patients are happier.

Sometimes change is unexpected

Even an ED has to be prepared for an emergency. During the H1N1 pandemic outbreak in 2009, the Alabama Department of Health required daily electronic reports with information on the number of patients presenting with flu symptoms, the number of patients tested and the number of patients confirmed with the virus. Without an EDIS, Huntsville Hospital would have had to manually review more than 400 patient charts to tally the information. With Wellsoft EDIS, a sort filter was created and reports were run automatically. On a daily basis, the required reports where downloaded to the Alabama Department of Health.

The ability to react quickly to state mandates allowed the ED staff to focus on their patients — not on paperwork.

Sometimes change helps others

Efficiency gains in one department should not slow down other departments in the hospital. Until recently, patients admitted into the hospital through the ED were typically upstairs before the admissions staff was notified. Adding a new process for case management provides a way for early notification of eminent admissions. After receiving an alert page, patients are evaluated to determine proper admit status.

The billing organization at Huntsville Hospital also strives for process improvements. One goal of this group is to streamline and generate a more accurate ED bill. After a cross-organizational hospital team assessed the billing system technology options available, the team decided to implement facility billing features in Wellsoft EDIS. Using charge-capture routines based on clinical documentation, procedures performed in the ED will have corresponding CMS service codes assigned. Chargeable items will be sent via HL7 to the Huntsville Hospital billing system.

It is anticipated that this change, currently being implemented, will increase revenue. Metrics will be put in place to measure success.

Change is ongoing

With the goal of being most efficient, the staff at Huntsville Hospital continually seeks ways to improve workflow and automate processes.

Huntsville Hospital credits the flexibility of their EDIS with their successful day-to-day management of their busy EDs. It also gives them the ability to adapt processes as necessary to achieve their goal to provide the best possible care in the most efficient manner.

 


Tracy Doughty is vice president of operations, emergency
and trauma services, Huntsville Hospital.
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