Patient flow management, adequate staffing levels and cost reductions are issues that hospital emergency departments deal with regularly. Recent studies have shown that emergency department visits are up in many hospitals across the United States. Additionally, the emergency department is the entry point for the majority of hospital inpatients. High patient volume and activity reinforces the importance of addressing patient flow, physician recruitment and best practices for efficient operations. A successful ED can be a vital element to a hospital's success.
Here Jeff Wood, RN, vice president of hospital based services of TeamHealth discusses how to address patient flow, physician recruitment and retention and other pertinent issues to increase the efficiency and financial success of a hospital emergency department.
Question: Reducing waiting times and improving patient flow are issues that emergency departments often need to tackle. How can hospitals address patient flow to improve the emergency department's operations?
Jeff Wood: Many hospitals attempt to improve emergency department patient flow through costly efforts such as adding staff, implementing new information systems or redesigning the physical layout of the department. They are often dismayed to find that these efforts [have] no positive impact on throughput times. [Instead] cost-effective strategies [such as] instituting a five-level triage process, a "pull-to-full" strategy, split-flow models, fast tracks, Quick-Pass and Lean can have a significant impact on patient flow.
Unfortunately, many hospitals struggle with implementing these strategies for two primary reasons. First, they aren't necessarily aware of all of the options available to them and don't have the expertise to accurately diagnose the bottlenecks in the department to apply the correct solutions. Secondly, they don't have a strong medical director and nurse manager leadership in place to establish urgency, implement the right changes, elicit buy-in from the staff, and measure results.
Q: Could you elaborate on those cost-effective strategies like Quick-Pass and Lean?
JW: Quick-Pass, also known as hot bedding, is an evidence-based practice designed to get a patient to a provider as quickly as possible. While some EDs refer to the process as immediate bedding, TeamHealth recommends branding the process of immediate bedding by calling it Quick-Pass. Doing so makes it easier to train, learn and implement. It also signals to the staff that we are "starting fresh" on this initiative and that we are not simply tweaking an existing, inefficient process. Quick-Pass is for use during non-peak times and any time in which there are open beds.
This practice improves patient flow, decreases physician-to-physician handoff time and improves the patient's experience and satisfaction. Quick-Pass improves front-end processes and metrics to allow patients to be placed into the right treatment space quickly and enhances the patient's perception of care and overall experience.
Another strategy — the Lean approach — apply numerous theories around reducing waste, improving the overall care environment, and decreasing bottlenecks to improve both the timeliness and quality of patient care in the ED. The approach begins by mapping out the flow of patients through the emergency department to determine each queuing interface. Lean builds on current staffing models to improve efficiency and improve patient access to care.
There is also the Lean Event approach, which engages groups of individuals and departments that support care in the ED in a multi-day process improvement exercise to improve flow and outcomes. We often find that organizations can accomplish a great deal in a short time if they have the benefit of outside, expert facilitation.
Q: Are there any other elements that increase an emergency room's efficiency?
JW: One primary initiative hospitals can implement to improve efficiency and more importantly, patient safety, is effective communication. [Communication is important] between emergency physicians at change of shift, with the hospitalist should the patient be admitted and to the patient when conveying discharge instructions. Post discharge phone calls are another effective tool to manage patient risk as they provide an opportunity to ensure that the patient is compliant with discharge instructions. Finally, there is added value if the emergency physicians can be members of a federally listed patient safety organization. By providing both privilege and confidentiality, a PSO creates a secure environment where physicians can collect, aggregate and analyze data to improve quality by identifying and reducing the risks associated with emergency patient care.
A strong risk management program is also essential for the fast-paced and efficient emergency medicine environment. A program grounded in evidence-based medicine can even reduce unnecessary ancillary costs and also reduce the physician's — and thus the hospital's — risk of a malpractice suit. As the front door to the hospital, a top-performing emergency department improves the hospital's image within its community, resulting in an increase in the hospital's overall market share and downstream revenue.
Q: You mentioned strong leadership as an important element for an efficient emergency room. How exactly do strong medical leaders impact the emergency setting?
JW: Strong leadership is essential for any organization that desires to effect change, and the ED is no different. The medical director sets the tone for the entire department and thus directly impacts staff morale, medical staff involvement, patient satisfaction, core measure compliance, patient throughput and finances. Unfortunately, leadership skills are not regularly taught in medical school, and many physicians are promoted to a medical director position without the necessary leadership experience or training to be effective. To be successful in this role, a medical director needs formal and ongoing leadership development training and extensive support from physician colleagues and administrative leaders.
Q: Since hospitals need physicians to take on leadership roles in the emergency department, how can they recruit and retain capable physicians before a leadership position is vacant?
JW: Some of the most effective means to recruit emergency physicians include word-of-mouth referrals, online job boards, direct mail campaigns, journal ads and trade shows. Unfortunately, these vehicles are often expensive for an individual hospital to implement. [Additionally,] an American College of Emergency Physicians "Emergency Medicine Workforce Study," shows there is a significant shortage of emergency physicians in the workforce, particularly those who are board certified and residency trained in emergency medicine. Emergency physicians receive approximately five job offers for every one that they accept. This shortage is a significant challenge facing [the healthcare] industry, particularly for hospitals in more rural markets.
[In order] to effectively recruit and retain emergency physicians, hospitals must be willing to expend the necessary resources to source quality candidates, be skilled at behavior-based interviewing and have a strong orientation [or] on-boarding program in place for new hires. The hospital should also conduct regular physician engagement surveys to identify areas for improving satisfaction and ultimately retention.
Strong recruitment and retention programs result in decreased recruiting and on-boarding costs, which reduces a reliance on temporary physicians or locum tenens, which for some hospitals can be extremely costly.
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Here Jeff Wood, RN, vice president of hospital based services of TeamHealth discusses how to address patient flow, physician recruitment and retention and other pertinent issues to increase the efficiency and financial success of a hospital emergency department.
Question: Reducing waiting times and improving patient flow are issues that emergency departments often need to tackle. How can hospitals address patient flow to improve the emergency department's operations?
Jeff Wood: Many hospitals attempt to improve emergency department patient flow through costly efforts such as adding staff, implementing new information systems or redesigning the physical layout of the department. They are often dismayed to find that these efforts [have] no positive impact on throughput times. [Instead] cost-effective strategies [such as] instituting a five-level triage process, a "pull-to-full" strategy, split-flow models, fast tracks, Quick-Pass and Lean can have a significant impact on patient flow.
Unfortunately, many hospitals struggle with implementing these strategies for two primary reasons. First, they aren't necessarily aware of all of the options available to them and don't have the expertise to accurately diagnose the bottlenecks in the department to apply the correct solutions. Secondly, they don't have a strong medical director and nurse manager leadership in place to establish urgency, implement the right changes, elicit buy-in from the staff, and measure results.
Q: Could you elaborate on those cost-effective strategies like Quick-Pass and Lean?
JW: Quick-Pass, also known as hot bedding, is an evidence-based practice designed to get a patient to a provider as quickly as possible. While some EDs refer to the process as immediate bedding, TeamHealth recommends branding the process of immediate bedding by calling it Quick-Pass. Doing so makes it easier to train, learn and implement. It also signals to the staff that we are "starting fresh" on this initiative and that we are not simply tweaking an existing, inefficient process. Quick-Pass is for use during non-peak times and any time in which there are open beds.
This practice improves patient flow, decreases physician-to-physician handoff time and improves the patient's experience and satisfaction. Quick-Pass improves front-end processes and metrics to allow patients to be placed into the right treatment space quickly and enhances the patient's perception of care and overall experience.
Another strategy — the Lean approach — apply numerous theories around reducing waste, improving the overall care environment, and decreasing bottlenecks to improve both the timeliness and quality of patient care in the ED. The approach begins by mapping out the flow of patients through the emergency department to determine each queuing interface. Lean builds on current staffing models to improve efficiency and improve patient access to care.
There is also the Lean Event approach, which engages groups of individuals and departments that support care in the ED in a multi-day process improvement exercise to improve flow and outcomes. We often find that organizations can accomplish a great deal in a short time if they have the benefit of outside, expert facilitation.
Q: Are there any other elements that increase an emergency room's efficiency?
JW: One primary initiative hospitals can implement to improve efficiency and more importantly, patient safety, is effective communication. [Communication is important] between emergency physicians at change of shift, with the hospitalist should the patient be admitted and to the patient when conveying discharge instructions. Post discharge phone calls are another effective tool to manage patient risk as they provide an opportunity to ensure that the patient is compliant with discharge instructions. Finally, there is added value if the emergency physicians can be members of a federally listed patient safety organization. By providing both privilege and confidentiality, a PSO creates a secure environment where physicians can collect, aggregate and analyze data to improve quality by identifying and reducing the risks associated with emergency patient care.
A strong risk management program is also essential for the fast-paced and efficient emergency medicine environment. A program grounded in evidence-based medicine can even reduce unnecessary ancillary costs and also reduce the physician's — and thus the hospital's — risk of a malpractice suit. As the front door to the hospital, a top-performing emergency department improves the hospital's image within its community, resulting in an increase in the hospital's overall market share and downstream revenue.
Q: You mentioned strong leadership as an important element for an efficient emergency room. How exactly do strong medical leaders impact the emergency setting?
JW: Strong leadership is essential for any organization that desires to effect change, and the ED is no different. The medical director sets the tone for the entire department and thus directly impacts staff morale, medical staff involvement, patient satisfaction, core measure compliance, patient throughput and finances. Unfortunately, leadership skills are not regularly taught in medical school, and many physicians are promoted to a medical director position without the necessary leadership experience or training to be effective. To be successful in this role, a medical director needs formal and ongoing leadership development training and extensive support from physician colleagues and administrative leaders.
Q: Since hospitals need physicians to take on leadership roles in the emergency department, how can they recruit and retain capable physicians before a leadership position is vacant?
JW: Some of the most effective means to recruit emergency physicians include word-of-mouth referrals, online job boards, direct mail campaigns, journal ads and trade shows. Unfortunately, these vehicles are often expensive for an individual hospital to implement. [Additionally,] an American College of Emergency Physicians "Emergency Medicine Workforce Study," shows there is a significant shortage of emergency physicians in the workforce, particularly those who are board certified and residency trained in emergency medicine. Emergency physicians receive approximately five job offers for every one that they accept. This shortage is a significant challenge facing [the healthcare] industry, particularly for hospitals in more rural markets.
[In order] to effectively recruit and retain emergency physicians, hospitals must be willing to expend the necessary resources to source quality candidates, be skilled at behavior-based interviewing and have a strong orientation [or] on-boarding program in place for new hires. The hospital should also conduct regular physician engagement surveys to identify areas for improving satisfaction and ultimately retention.
Strong recruitment and retention programs result in decreased recruiting and on-boarding costs, which reduces a reliance on temporary physicians or locum tenens, which for some hospitals can be extremely costly.
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